HESI Fundamentals

Questions 54

HESI RN

Home > HESI RN > HESI Fundamentals of Nursing > HESI Fundamentals
HESI RN Test Bank

HESI Fundamentals Questions

Question 1 of 5

The client has a chest tube. What is the most important action for the nurse to take?

Correct Answer: C

Rationale: Keeping the drainage system below the level of the chest (C) is crucial to ensure proper drainage and prevent backflow of air or fluid into the chest cavity. This position helps maintain the integrity of the closed drainage system. Ensuring the chest tube remains unclamped at all times (A) allows for continuous drainage. Emptying the chest tube (B) should be done as needed, not routinely every 2 hours. Assessing for subcutaneous emphysema (D) is important but not the most critical action in this scenario.

Question 2 of 5

When assisting an older adult client in preparing to take a tub bath, which nursing action is most important?

Correct Answer: A

Rationale: The most crucial nursing action when assisting an older adult client with a tub bath is to check the bath water temperature. This step is essential to prevent burns from hot water or chilling from water that is too cold. Ensuring the water temperature is safe is a critical aspect of promoting the client's safety and comfort during the bathing process.

Question 3 of 5

While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement?

Correct Answer: A

Rationale: The client is exhibiting symptoms of normal grief, such as flat affect, withdrawal, and sleep disturbances, following the recent death of his life partner. It is crucial for the nurse to encourage the client to see the clinic's grief counselor. Grief counseling can provide the client with appropriate support and coping strategies during this grieving process, helping him navigate through his loss and emotions effectively.

Question 4 of 5

When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next?

Correct Answer: A

Rationale: The nurse should record the amount on the client's fluid output record because the 350 mL of pale yellow urine is a normal finding. This indicates appropriate urine output, so encouraging increased fluid intake or notifying the healthcare provider is not necessary at this time. Additionally, palpating the client's bladder for distention is not indicated based on the normal urine output observed.

Question 5 of 5

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?

Correct Answer: A

Rationale: The priority nursing action is to restore circulation by loosening the restraint (A) because blue fingers (cyanosis) indicate decreased circulation. Comparing hand color bilaterally (C) and palpating the right radial pulse (D) are important assessments to gather more information, but they do not have the priority of addressing the decreased circulation by loosening the restraint. Applying a pulse oximeter (B) is not indicated in this scenario as it measures the saturation of hemoglobin with oxygen, which is not relevant when cyanosis is related to mechanical compression from the restraints.

Similar Questions

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?
UAP has lowered the head of the bed to change the linens for a client who is bedbound with a foley catheter and enteral tube feeds. Which change from the client warrants the most immediate intervention by the nurse?
A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with malodorous green drainage. Which dressing is best for the nurse to use first?
A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best?
A client with a diagnosis of hyperthyroidism is being discharged. Which instruction should the nurse include in the discharge teaching?

Join Our Community Today!

Join Over 10,000+ nursing students using Nurselytic. Access Comprehensive study Guides curriculum for HESI-RN and 3000+ practice questions to help you pass your HESI-RN exam.

Call to Action Image