HESI Fundamentals

Questions 54

HESI RN

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HESI Fundamentals Questions

Question 1 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 2 of 5

The healthcare provider attaches a pulse oximeter to a client's fingers and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Correct Answer: B

Rationale: Edema in the fingers and hands can impede the proper functioning of the pulse oximeter, leading to a falsely low oxygen saturation reading. Edema alters the transmission of light through the tissues, affecting the accuracy of the measurement. Therefore, the presence of edema in the fingers and hands is the most likely factor contributing to the low oxygen saturation reading of 91%.

Question 3 of 5

Earlier this morning, an elderly Hispanic female was discharged to a LTC facility. The family members are now gathered in the hallway outside her room. What is the best action?

Correct Answer: B

Rationale: In this situation, providing space and privacy for the family allows them to openly discuss their concerns regarding the client's discharge. It respects the family's need for support, communication, and involvement in the decision-making process, ultimately fostering a more effective and compassionate care environment.

Question 4 of 5

Which client care task requires the nurse to wear barrier gloves as mandated by the Standard Precautions protocol?

Correct Answer: D

Rationale: The correct answer is D because emptying a urinary catheter drainage bag exposes the nurse to body fluids, necessitating the use of barrier gloves as per Standard Precautions to prevent potential infection transmission.

Question 5 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.

Similar Questions

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?
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?
What action should be taken when adding sterile liquids to a sterile field?
When caring for an older incontinent client at risk for infection, which intervention is best for the nurse to implement based on the nursing diagnosis of risk for infection?
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement?

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