Fundamentals HESI

Fundamentals HESI Related

Review Fundamentals HESI related questions and content

When preparing for a change of shift, which document or tools should a healthcare provider use to communicate?

  • A. SBAR
  • B. SOAP
  • C. PIE
  • D. DAR
Correct Answer: A

Rationale: The correct answer is A: SBAR (Situation, Background, Assessment, Recommendation) is a structured method for communicating information during shift changes. SBAR provides a clear and concise way for healthcare providers to communicate important details about a patient's condition, ensuring that essential information is effectively transferred between providers. Choice B, SOAP (Subjective, Objective, Assessment, Plan), is a method primarily used for documentation in patient charts, not for shift change communication. Choice C, PIE (Problem, Intervention, Evaluation), is a nursing process format for organizing nursing care that focuses on individualized patient care plans, not shift handoff communication. Choice D, DAR (Data, Action, Response), is not a standard format for provider-to-provider handoff communication and is less commonly used in healthcare settings compared to SBAR.

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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.

A healthcare professional is using the I-SBAR communication tool to provide the client's provider with information about the client. The healthcare professional should convey the client's pain status in which portion of the report?

  • A. Assessment
  • B. Situation
  • C. Background
  • D. Recommendation
Correct Answer: A

Rationale: In the I-SBAR communication tool, the 'Assessment' portion is where the healthcare professional should convey the client's pain status. This section includes the current patient information, such as the client's pain level, to provide a comprehensive view of the client's condition. Choice B ('Situation') typically involves a brief summary of the client's problem or reason for the communication. Choice C ('Background') usually covers the client's medical history and background information. Choice D ('Recommendation') focuses on the healthcare professional's suggestions or requests regarding the client's care plan, which may include pain management strategies but not the current pain status.

When assessing a client's IV for infiltration, which finding would be unexpected for the nurse?

  • A. The area around the infusion site feels warm to the touch.
  • B. The infusion site is swollen and cool to the touch.
  • C. The infusion line does not flush properly.
  • D. There is no blood return in the infusion line.
Correct Answer: A

Rationale: The correct answer is A. Warmth around the infusion site is not an expected finding with infiltration. Infiltration typically presents with swelling and coolness due to the fluid leaking into the surrounding tissue. Choices B, C, and D are incorrect because swelling, coolness, and difficulty flushing the line, as well as lack of blood return, are commonly associated with infiltration.

A client is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?

  • A. Monitor the client for pain in the suprapubic region.
  • B. Ensure the client is free of metal objects.
  • C. Administer 240 mL (8 oz) of oral contrast before the procedure.
  • D. Assist the client with a bowel cleansing.
Correct Answer: B

Rationale: The correct action for the nurse to include before an intravenous pyelogram is ensuring the client is free of metal objects. Metal objects can interfere with the imaging procedure and may need to be removed to prevent artifacts. Monitoring for pain in the suprapubic region (choice A) is not directly related to the procedure and is not a standard pre-procedure action. Administering oral contrast (choice C) is more common for other imaging studies like a CT scan, not an intravenous pyelogram. Assisting with a bowel cleansing (choice D) is not typically required before an intravenous pyelogram.

A client who has just had a mastectomy has a closed wound suction device (hemovac) in place. Which nursing action will ensure proper operation of the device?

  • A. Collapsing the device whenever it is 1/2 to 2/3 full of air.
  • B. Emptying the device every 4 hours.
  • C. Replacing the device every 24 hours.
  • D. Keeping the device above the level of the surgical site.
Correct Answer: A

Rationale: Collapsing the device when it is 1/2 to 2/3 full of air is the correct nursing action to ensure proper operation of a closed wound suction device (hemovac). This action maintains negative pressure, which is essential for proper suction and drainage of the wound. Emptying the device every 4 hours (Choice B) is not necessary as the focus should be on collapsing it appropriately. Replacing the device every 24 hours (Choice C) is not a standard practice unless indicated by the healthcare provider. Keeping the device above the level of the surgical site (Choice D) is not necessary for the device's proper operation; collapsing it to maintain negative pressure is the key action.

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