HESI RN
HESI Quizlet Fundamentals Questions
Question 1 of 5
A client with chronic kidney disease is receiving peritoneal dialysis. Which assessment finding should the nurse report to the healthcare provider immediately?
Correct Answer: B
Rationale: Cloudy peritoneal effluent (B) is a sign of infection and should be reported to the healthcare provider immediately. It indicates the presence of peritonitis, a severe complication that requires prompt intervention. Weight gain (A) may indicate fluid overload but is not as urgent as a potential infection. Elevated blood pressure (C) is a common finding in clients with kidney disease and needs monitoring but does not require immediate reporting. Clear and pale yellow effluent (D) is a normal finding and does not raise immediate concerns.
Question 2 of 5
During the suctioning of a tracheostomy tube, if the catheter appears to attach to the tracheal walls and creates a pulling sensation, what is the best action for the nurse to take?
Correct Answer: A
Rationale: When the catheter of the suctioning device attaches to the tracheal walls, causing a pulling sensation, the nurse should release the suction by opening the vent. This action will alleviate the pulling sensation and prevent trauma to the delicate tracheal walls. Continuing suctioning or applying more pressure can lead to tissue damage and should be avoided. Suctioning deeper can increase the risk of injuring the patient's airway.
Question 3 of 5
Which intervention is most important to include in the plan of care for a client at high risk for the development of postoperative thrombus formation?
Correct Answer: D
Rationale: Thrombus formation is a risk for clients who are immobile postoperatively. Encouraging frequent ambulation helps to prevent stasis in the lower extremities, reducing the risk of thrombus formation. This intervention promotes circulation and prevents blood clot formation, making it the most important intervention in this situation.
Question 4 of 5
An elderly patient has been living in a nursing home for several years. The nursing staff has begun to notice a change in her behavior. All of the following are symptoms of depression except:
Correct Answer: D
Rationale: Hyperorality is not typically a symptom of depression. Symptoms of depression often include changes in sleep patterns, eating patterns with weight loss, and excessive fatigue. Hyperorality, which refers to the tendency to examine, chew, or ingest non-nutritive substances, is not a common symptom associated with depression.
Question 5 of 5
A client is admitted to the hospital with a diagnosis of pneumonia. Which laboratory test result should the nurse monitor to evaluate the client's respiratory function?
Correct Answer: A
Rationale: Arterial blood gases (ABGs) are the most appropriate laboratory test to monitor respiratory function in a client with pneumonia. ABGs provide valuable information on oxygenation status, acid-base balance, and how well the lungs are exchanging gases. This information helps in assessing the effectiveness of ventilation and oxygenation, guiding treatment decisions, and evaluating the overall respiratory status of the client.
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