HESI Fundamentals 2023 Test Bank

HESI Fundamentals 2023 Test Bank Related

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A healthcare professional is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the healthcare professional include in the plan?

  • A. Empty the drainage bag at least every 8 hours
  • B. Keep the drainage bag below the level of the bladder
  • C. Use sterile technique to collect a specimen from the drainage system
  • D. Secure the catheter to the lower abdomen with a securement device
Correct Answer: B

Rationale: The correct action to include in the plan is to keep the drainage bag below the level of the bladder. This positioning helps ensure proper drainage and prevents backflow of urine into the bladder, reducing the risk of urinary tract infections. Emptying the drainage bag regularly is important, typically every 4-8 hours or when it is half-full, to maintain adequate flow and prevent infection (Choice A is incorrect). Using a sterile technique to collect specimens from the drainage system is crucial to prevent introducing pathogens into the urinary tract, so clean technique should not be used (Choice C is incorrect). Taping the catheter to the lower abdomen is not recommended as it can cause tension on the catheter, leading to discomfort and potential trauma to the urethra (Choice D is incorrect).

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What instruction should the nurse provide for a UAP caring for a client with MRSA who has a prescription for contact precautions?

  • A. Allow visitors with precautions in place
  • B. Wear sterile gloves when handling the client's body fluid
  • C. Have the client wear a mask whenever someone enters the room
  • D. Don a gown and gloves when entering the room
Correct Answer: D

Rationale: The correct instruction for a UAP caring for a client with MRSA under contact precautions is to don a gown and gloves when entering the room. Wearing a gown and gloves is necessary to prevent the transmission of MRSA. Choice A is incorrect because visitors may be allowed with proper precautions in place. Choice B is incorrect as it assumes the client has body fluid precautions, which is not specified. Choice C is incorrect as it does not address the UAP's protective measures but rather focuses on the client wearing a mask.

A client with chronic renal failure selects scrambled eggs for breakfast. What action should the LPN/LVN take?

  • A. Commend the client for selecting a high biological value protein.
  • B. Remind the client that protein in the diet should be avoided.
  • C. Suggest that the client also select orange juice to promote absorption.
  • D. Encourage the client to attend classes on dietary management of chronic renal failure.
Correct Answer: A

Rationale: The correct action is to commend the client for selecting a high biological value protein, as scrambled eggs provide a good protein source for clients with chronic renal failure. Protein is essential for maintaining muscle mass and overall health in these clients. Reminding the client to avoid protein is incorrect as it may lead to protein-energy malnutrition, which is a common concern in chronic renal failure. Suggesting orange juice for absorption is not relevant to the situation, as protein absorption is not a primary concern in this context. Encouraging the client to attend classes on dietary management of chronic renal failure is important for overall education but is not the immediate action needed in response to the client's breakfast choice.

A patient has scaling of the scalp. Which term will the nurse use to report this finding to the oncoming staff?

  • A. Dandruff
  • B. Alopecia
  • C. Pediculosis
  • D. Xerostomia
Correct Answer: A

Rationale: The correct term the nurse will use to report scaling of the scalp is 'Dandruff.' Dandruff is characterized by scaling of the scalp that is often accompanied by itching. Choice B, 'Alopecia,' refers to hair loss, not scaling. Choice C, 'Pediculosis,' is the infestation of lice, not scaling. Choice D, 'Xerostomia,' pertains to dry mouth, which is unrelated to the described symptom of scaling of the scalp.

A client with a diagnosis of myocardial infarction (MI) is being treated. Which laboratory value would be most concerning?

  • A. Troponin level of 0.5 ng/mL
  • B. Creatine kinase-MB (CK-MB) of 5.0 ng/mL
  • C. Serum potassium of 4.5 mEq/L
  • D. Blood glucose of 180 mg/dL
Correct Answer: A

Rationale: A troponin level of 0.5 ng/mL is elevated, indicating myocardial damage, making it the most concerning finding in a client with a myocardial infarction (MI). Troponin is a highly specific marker for cardiac muscle damage, and elevated levels suggest ongoing injury to the heart muscle. While Creatine kinase-MB (CK-MB) is also a cardiac enzyme, troponin is more specific and sensitive for myocardial damage. Serum potassium and blood glucose levels are important parameters to monitor in MI patients, but in this scenario, the elevated troponin level takes precedence as it directly reflects cardiac injury.

A nurse is teaching the parents of a toddler about discipline. Which of the following actions should the nurse suggest?

  • A. Establish consistent boundaries for the toddler.
  • B. Place the toddler in a room with the door closed.
  • C. Inform the toddler how you feel when he misbehaves.
  • D. Use a favorite snack to reward the toddler.
Correct Answer: A

Rationale: The correct answer is to establish consistent boundaries for the toddler. This approach helps toddlers understand expectations and promotes consistent behavior. Placing the toddler alone or using food rewards may not effectively teach discipline and could be inappropriate. Informing the toddler about feelings when misbehaving may not be developmentally appropriate for a toddler to understand the consequences of their actions.

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