Fundamentals HESI

Fundamentals HESI Related

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A hospitalized client needs a chest x-ray. The radiology department calls the nursing unit and says that they are sending a transporter for the client. When entering the client's room, the priority action is to:

  • A. Check the client's identification bracelet
  • B. Inform the client about the procedure
  • C. Prepare the client for transport
  • D. Verify the x-ray order
Correct Answer: A

Rationale: The correct action to take when a transporter arrives to take a hospitalized client for a procedure is to check the client's identification bracelet. This step is crucial to prevent errors and ensure that the correct patient is receiving the intended procedure. Informing the client about the procedure and preparing them for transport are important steps in the process, but verifying the client's identity takes precedence to ensure patient safety. Verifying the x-ray order, though important, is not the priority action when the transporter arrives; confirming the patient's identity is essential before proceeding with any procedures.

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During a family assessment, a nurse is interviewing a family composed of a husband, a wife, and three children. One child is biological from this marriage, and the other two are from the wife's previous marriage. How should the nurse identify this family form?

  • A. Extended
  • B. Blended
  • C. Nuclear
  • D. Alternative
Correct Answer: B

Rationale: The correct answer is 'Blended.' This family is considered a blended family because it consists of children from previous marriages, along with the biological child of the current marriage. Choice A ('Extended') refers to a family that includes relatives beyond the nuclear family, such as grandparents or aunts/uncles. Choice C ('Nuclear') typically consists of a husband, wife, and their biological children only. Choice D ('Alternative') does not accurately describe the family structure presented in the scenario.

A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?

  • A. Evaluate electrolytes
  • B. Restrict fluid intake
  • C. Administer diuretics
  • D. Monitor vital signs
Correct Answer: A

Rationale: When a client has fluid overload, the nurse's first action should be to evaluate electrolytes. Electrolyte levels can be significantly affected by fluid imbalances, and assessing them will guide the nurse in determining the appropriate interventions. Restricting fluid intake (choice B) may be necessary but is not the initial priority. Administering diuretics (choice C) should be based on the electrolyte evaluation and overall assessment. Monitoring vital signs (choice D) is essential but does not provide direct information on the client's electrolyte status, which is crucial in managing fluid overload.

The nurse is providing oral care to a patient. In which order will the nurse clean the oral cavity, starting with the first area?

  • A. Roof of mouth, gums, and inside cheeks
  • B. Chewing and inner tooth surfaces
  • C. Outer tooth surfaces
  • D. Tongue
Correct Answer: C

Rationale: The correct sequence for oral care is to clean the outer tooth surfaces first, followed by cleaning the inner tooth surfaces, then the roof of the mouth, gums, and inside cheeks with a toothette. Brushing the tongue should be the final step in the oral care procedure. Therefore, option C is the correct choice. Options A, B, and D are incorrect because they do not follow the correct order for providing oral care to a patient.

The nurse is providing discharge teaching to a client who has a new prescription for digoxin (Lanoxin). Which statement by the client indicates a need for further teaching?

  • A. I will take my pulse before taking the medication.
  • B. I will take the medication at the same time every day.
  • C. I should avoid taking antacids at the same time as this medication.
  • D. I should eat foods high in potassium while taking this medication.
Correct Answer: D

Rationale: The correct answer is D. Clients taking digoxin should avoid eating foods high in potassium, as this can affect the medication's efficacy. Choices A, B, and C are correct statements regarding digoxin administration and precautions, indicating the client's understanding of the medication and its management.

During an admission history assessment, a client informs the nurse about consuming herbal tea every afternoon at work to alleviate stress. What ingredient is likely present in the tea?

  • A. Chamomile
  • B. Ginseng
  • C. Ginger
  • D. Echinacea
Correct Answer: A

Rationale: The correct answer is A: Chamomile. Chamomile tea is commonly used for stress relief. Choice B, Ginseng, is not typically used in teas for stress relief but for energy and immune system support. Choice C, Ginger, is more commonly used for digestive health and nausea. Choice D, Echinacea, is often used to boost the immune system. Therefore, in the context of stress relief, Chamomile is the most appropriate ingredient.

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