HESI Fundamentals Study Guide

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The patient is being treated for cancer with weekly radiation therapy to the head and intravenous chemotherapy treatments. Which assessment is the priority?

  • A. Feet
  • B. Nail beds
  • C. Perineum
  • D. Oral cavity
Correct Answer: D

Rationale: The correct answer is the oral cavity. During cancer treatment involving radiation to the head and intravenous chemotherapy, the oral cavity is a priority assessment area. Radiation can reduce salivary flow and lower the pH of saliva, which can lead to stomatitis and tooth decay. Assessing the oral cavity allows for the early identification and management of potential complications.

Choice A, assessing the feet, is not the priority in this scenario as it is not directly impacted by the described cancer treatments.

Choice B, assessing the nail beds, is not the priority compared to the oral cavity. Nail bed assessment may be relevant for certain conditions, but in this case, the oral cavity is of higher priority due to the specific treatment effects.

Choice C, assessing the perineum, is also not the priority in this situation as it is not directly affected by the described cancer treatments, unlike the oral cavity.

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A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?

  • A. Activate the emergency fire alarm
  • B. Extinguish the fire
  • C. Evacuate the client
  • D. Confine the fire
Correct Answer: C

Rationale: The correct action for the nurse to take next, after confirming the fire, is to evacuate the client. In a fire situation, following the RACE mnemonic, the priority is to rescue or evacuate clients to ensure their safety. Activating the emergency fire alarm (Choice A) is important to alert others and the fire department, but evacuating the client takes precedence. Extinguishing the fire (Choice B) may put the nurse and client at risk and is best left to trained personnel. Confining the fire (Choice D) is not the nurse's responsibility; the focus should be on ensuring the client's safety by evacuating them.

The client has been diagnosed with deep vein thrombosis (DVT). Which symptom would be most concerning?

  • A. Pain in the affected leg
  • B. Redness and warmth in the affected leg
  • C. Shortness of breath
  • D. Swelling in the affected leg
Correct Answer: C

Rationale: Shortness of breath is the most concerning symptom in a client with deep vein thrombosis (DVT) because it could indicate a pulmonary embolism, a life-threatening complication where a blood clot travels to the lungs. This condition requires immediate medical attention. While pain, redness, warmth, and swelling in the affected leg are common symptoms of DVT, shortness of breath suggests a more critical situation that necessitates urgent intervention.

A client has been sitting in a chair for 1 hour. Which of the following complications poses the greatest risk to the client?

  • A. Decreased subcutaneous fat
  • B. Muscle atrophy
  • C. Pressure injury
  • D. Fecal impaction
Correct Answer: C

Rationale: The correct answer is C: Pressure injury. Prolonged sitting can lead to pressure injuries due to continuous pressure on certain body areas, reducing blood flow and causing tissue damage. While decreased subcutaneous fat, muscle atrophy, and fecal impaction are potential concerns, pressure injuries pose the greatest immediate risk as they can lead to serious complications such as tissue necrosis and infection if not addressed promptly. Decreased subcutaneous fat and muscle atrophy may develop over time with prolonged immobility but are not as acutely dangerous as a pressure injury. Fecal impaction, while uncomfortable and potentially serious, does not pose an immediate life-threatening risk compared to the development of a pressure injury.

At the surgical scrub sink, a surgical nurse demonstrated the proper surgical handwashing technique by scrubbing:

  • A. With her hands held lower than her elbows
  • B. With her hands held higher than her elbows
  • C. With her hands in a fist position
  • D. With hands placed on her chest
Correct Answer: B

Rationale: The correct technique for surgical handwashing involves scrubbing with hands held higher than the elbows. This positioning helps prevent water from the contaminated area (the hands) from flowing towards the cleaner area (the elbows). This directional flow minimizes the risk of contaminating the scrubbed hands during the handwashing process. Choices A, C, and D are incorrect: A - having hands lower than elbows would risk contamination of the clean area, C - using a fist position does not ensure proper coverage and thorough handwashing, and D - placing hands on the chest is not part of the proper surgical handwashing technique.

While providing care to a group of patients, which patient should the nurse prioritize seeing first?

  • A. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea
  • B. A bedridden patient with a reddened area on the buttocks who needs to be turned
  • C. A patient on bed rest with renal calculi who needs to go to the bathroom
  • D. A patient post-knee surgery who needs range of motion exercises
Correct Answer: A

Rationale: The nurse should prioritize seeing the patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea first. This patient is at higher risk for deep vein thrombosis due to prolonged bed rest, which can lead to a life-threatening embolus. Chest pain and dyspnea could also indicate a potential pulmonary embolism, which requires immediate assessment and intervention. The other patients, while requiring care, do not present with symptoms that suggest an immediate life-threatening situation, making them lower priority at this time. Therefore, option A is the correct choice as it addresses a potentially critical condition that requires immediate attention.

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