HESI Fundamentals

Questions 54

HESI RN

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HESI Fundamentals Questions

Question 1 of 5

The nurse explains to an older adult male the procedure for collecting a 24-hour urine specimen for creatinine clearance. Which action is most important for the nurse to include in their care plan for the shift?

Correct Answer: C

Rationale: To ensure accurate creatinine clearance results, it is crucial to collect all urine within the 24-hour period. The process should begin with discarding the first specimen and then collecting all subsequent urine in the designated 24-hour collection container. This ensures that the sample is complete and accurate for the creatinine clearance calculation.

Question 2 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 3 of 5

A client being discharged with a prescription for the bronchodilator theophylline is instructed to take three doses of the medication each day. Since timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow?

Correct Answer: B

Rationale: Theophylline should be administered on a regular around-the-clock schedule to provide the best bronchodilating effect and reduce the potential for adverse effects. The correct dosing schedule of 8 a.m., 4 p.m., and midnight ensures that the client receives consistent dosing throughout the day. Other options do not provide the necessary around-the-clock coverage. It's important to note that food may affect the absorption of the medication, which is why the dosing schedule should not be tied to meal times.

Question 4 of 5

The patient had a CVA and developed right-sided hemiplegia. Which action is least appropriate for the nurse to take?

Correct Answer: C

Rationale: Suctioning the patient in a supine position and pulling the bed sheets tightly across their feet can lead to foot drop, which is harmful for a patient with right-sided hemiplegia. This action can exacerbate muscle weakness and impair circulation in the affected limb. It is crucial to avoid actions that may compromise the patient's safety and well-being, such as causing foot drop in this scenario.

Question 5 of 5

At 0100 on a male client's second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?

Correct Answer: A

Rationale: The client has expressed a plan to read until feeling sleepy, indicating that he is managing his inability to sleep. In this situation, it is best for the nurse to respect the client's autonomy and leave the room, providing privacy and an opportunity for the client to relax and hopefully fall asleep. Closing the door can also help create a quiet environment conducive to rest.

Similar Questions

At 0100 on a male client's second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?
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When suctioning a tracheostomy, which action is most appropriate for the nurse to take?
The healthcare provider obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the healthcare provider implement first?
The healthcare provider is conducting an initial admission assessment for a woman who is Mexican-American and who is scheduled to deliver a baby by C-section in the next 24 hours. What should the healthcare provider include in the assessment?

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