HESI Fundamentals Quizlet

Questions 54

HESI RN

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HESI Fundamentals Quizlet Questions

Question 1 of 5

An adult has a coagulation time of 20 minutes. The nurse should observe the client for which of the following?

Correct Answer: B

Rationale: A coagulation time of 20 minutes is prolonged, suggesting a potential bleeding disorder. Ecchymotic areas, which are areas of bruising, are common signs of abnormal bleeding. Therefore, the nurse should observe the client for ecchymotic areas to monitor for potential bleeding issues.

Question 2 of 5

Which intervention is most important when caring for a client with a chest tube?

Correct Answer: D

Rationale: The most crucial intervention when caring for a client with a chest tube is to ensure that the chest tube is connected to a water-seal drainage system (D). This system helps maintain proper lung expansion and prevents complications. Keeping the drainage system at chest level (A) is important to facilitate drainage, but not as critical as ensuring the connection to the drainage system. Clamping the chest tube (B) is unnecessary and can lead to serious issues. Stripping the chest tube (C) is an outdated practice and can cause harm rather than benefit.

Question 3 of 5

A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment because she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

Correct Answer: C

Rationale: The correct answer is C. For droplet precautions, such as in the case of pertussis, a standard face mask is sufficient for protection. Particulate filter masks are required for airborne precautions, not for droplet precautions. Therefore, the UAP can proceed with taking the vital signs using a standard mask without the need for a particulate filter mask. It is important for healthcare workers to understand the appropriate use of personal protective equipment based on the type of precautions in place to provide safe and effective care to clients.

Question 4 of 5

When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum 'tents' when gently pinched. Which action should the nurse implement?

Correct Answer: C

Rationale: When the nurse observes that the client's skin over the sternum 'tents' when gently pinched, it is a classic sign of fluid volume deficit. The appropriate action for the nurse in this situation is to continue the planned nursing interventions aimed at restoring the client's fluid volume. This finding reinforces the need to address the fluid deficit and support the client's recovery.

Question 5 of 5

In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible?

Correct Answer: A

Rationale: Black sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the health care provider promptly.

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An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client is capable of giving the daily injection. Which response by the nurse is likely to be most helpful in encouraging the client to assume total responsibility for the daily injections?

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