HESI Fundamentals Quizlet

Correct Answer: D

Rationale: The correct action for the nurse to take first in this situation is to compare the current blood pressure reading with the client's previously documented readings. This comparison will provide valuable information about what is normal for this specific client, helping to determine if the current reading represents a significant change or if it falls within the client's usual range. This step is essential for appropriate decision-making and planning further care.

Correct Answer: B

Rationale: Proper handwashing technique is crucial in preventing the transmission of infections, especially in clients with burns where the risk of infection is high. It is the most effective intervention to reduce the risk of contamination and promote healing in these clients. While plasma expanders, topical antibacterial creams, and visitor restrictions are important considerations in burn care, meticulous hand hygiene takes precedence in preventing infections.

Correct Answer: B

Rationale: Avoiding foods high in sodium (choice B) is essential for clients with heart failure to prevent fluid retention and decrease the strain on the heart. High sodium intake can lead to fluid buildup, exacerbating heart failure symptoms. Increasing potassium intake (choice A) can be harmful in heart failure if not monitored closely. Limiting fluid intake (choice C) may be necessary in some cases, but the specific amount should be individualized based on the client's condition. Increasing vitamin K intake (choice D) is not a primary concern in heart failure management.

Correct Answer: A

Rationale: Monitoring daily weights is an accurate method to assess the effectiveness of fluid replacement therapy because changes in weight reflect changes in fluid balance. Fluid volume deficit can be objectively evaluated by monitoring daily weights as it provides a more precise measurement of fluid status over time.

Correct Answer: B

Rationale: In this situation, the healthcare provider should first check for kinks in the tubing and raise the IV pole. These are common causes of a slowed IV rate and should be addressed before considering other interventions.