HESI Fundamentals Quizlet

Questions 54

HESI RN

HESI RN Test Bank

HESI Fundamentals Quizlet Questions

Question 1 of 5

A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?

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.

Question 2 of 5

The healthcare provider identifies a potential for infection in a client with partial-thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection?

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.

Question 3 of 5

The client has received a new diagnosis of heart failure, and the nurse is providing dietary management education. Which instruction should the nurse include?

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.

Question 4 of 5

The healthcare provider is caring for a client who is experiencing fluid volume deficit (dehydration). Which intervention should the healthcare provider implement to assess the effectiveness of fluid replacement therapy?

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.

Question 5 of 5

The healthcare provider assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the healthcare provider do next?

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.

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