HESI Fundamentals - Set 5 - Part 2

Correct Answer: Increased redness, warmth, drainage, fever

Increased redness, warmth, purulent drainage, increased pain, and fever signal possible wound infection. The patient should call the surgeon's office, since prompt evaluation may prevent progression and the need for hospital readmission. Option a is incorrect because Mild scab formation in the first week is part of normal healing and does not require notification. The patient should still keep the incision clean and dry, but a scab alone does not signal a complication. Option b is incorrect because Slight tenderness during the first days is also part of normal healing. Pain that is mild and improving does not warrant a call, although increasing or severe pain is part of the warning list. Option c is incorrect because Slight pink edges of an incision early in healing reflect normal inflammation and tissue repair. The color generally fades as healing continues, and the finding alone is not concerning during the first days at home.

Correct Answer: Use both meds, never exceed acetaminophen limit

Using both medications together for multimodal analgesia controls pain with lower opioid exposure. The patient must not exceed the daily acetaminophen limit, since hepatotoxicity is a serious risk with sustained doses above the threshold. Option a is incorrect because Taking a double dose for severe pain is unsafe because the patient could exceed the safe limit of either medication. The patient should follow prescribed dosing and contact the prescriber if pain control is inadequate. Option c is incorrect because Avoiding acetaminophen and relying only on opioids increases opioid exposure and the side effect burden. Multimodal analgesia is the recommended approach because it pairs different mechanisms and lowers the total opioid requirement. Option d is incorrect because Stopping opioids at the first mild pain may leave the patient suddenly in worse pain later. The patient should follow the tapering plan and continue acetaminophen, with opioids used as needed for breakthrough pain.

Correct Answer: Walk daily, avoid heavy lifting, follow surgeon

Daily walking supports recovery, while avoiding heavy lifting protects the incision and surgical repair. The patient checks specific limits with the surgeon, especially regarding driving and resumption of work, since these vary by procedure type. Option a is incorrect because Resuming all activity immediately ignores the need for healing and protection. Some activities can disrupt the surgical repair or increase pain, so a gradual increase guided by the surgeon's instructions is the safer approach. Option b is incorrect because Avoiding all walking for several weeks risks deconditioning and venous thromboembolism. Patients usually walk daily during recovery, with limits placed only on the more strenuous activities like heavy lifting and certain sports. Option d is incorrect because Driving immediately is unsafe if the patient is on opioids or has limited range of motion. The patient should confirm with the surgeon and consider reaction time, sedation, and the type of surgery befor

Correct Answer: Sudden calf swelling, warmth, redness, pain

Sudden calf swelling, warmth, redness, and pain suggest deep vein thrombosis. The patient should seek care promptly, since untreated clots can break free and travel to the lungs as a pulmonary embolism with serious consequences. Option b is incorrect because Mild ankle stiffness in the morning is common after surgery and does not signal deep vein thrombosis. The finding is unrelated to clot formation and resolves as the patient moves through the day. Option c is incorrect because Rare brief twinges in the foot are not specific for deep vein thrombosis. The findings worth reporting are more sustained calf swelling, warmth, redness, and pain rather than brief sensations during normal recovery. Option d is incorrect because Slight skin dryness on the calves is unrelated to deep vein thrombosis. The cue list focuses on swelling, warmth, redness, and pain, which reflect inflammation and clot formation rather than skin texture changes.

Correct Answer: Have responsible adult drive and stay

A responsible adult should drive the patient home and stay overnight after general anesthesia. The patient avoids driving, signing legal documents, and operating complex machinery for at least twenty-four hours due to residual sedation and impaired judgment. Option a is incorrect because Driving home after general anesthesia is unsafe because of residual sedation and slowed reflexes. The patient cannot legally drive while under the lingering effects, and arranging a ride home is part of standard pre-op planning. Option b is incorrect because Signing legal documents on the day is not advised because judgment may be impaired by anesthesia. Important decisions should wait until full mental clarity returns, typically the next day or later, depending on individual recovery. Option c is incorrect because Operating complex machinery the same day is dangerous given residual anesthesia effects. The patient should rest and avoid tasks requiring sharp coordination or judgment until cleared and fe

Correct Answer: Use open-ended question to learn more

Open-ended questions invite the patient to share more about feelings and thoughts. The technique supports therapeutic communication and helps the nurse understand the underlying concern, which guides further discussion and emotional support during the encounter. Option a is incorrect because Changing the subject avoids the topic and ends therapeutic communication. The patient may feel dismissed and the underlying concern remains unaddressed, which damages trust and prevents the nurse from supporting the patient effectively. Option b is incorrect because False reassurance such as nothing bad will happen is non-therapeutic. The nurse cannot guarantee outcomes, and offering blanket reassurance shuts down conversation rather than encouraging the patient to discuss the actual worry. Option d is incorrect because Giving the nurse's own opinion on the procedure shifts focus away from the patient. Therapeutic communication centers the patient's experience, and the nurse listens and r

Correct Answer: Why did you let this happen

Why questions that imply blame are non-therapeutic and shut down dialogue. The phrasing puts the patient on the defensive and damages trust, leaving feelings unspoken and preventing further productive conversation in the encounter. Option b is incorrect because Asking the patient to share more is therapeutic and invites continued conversation. The technique uses an open-ended invitation that supports the patient in expressing concerns more fully throughout the conversation as it develops. Option c is incorrect because Reflecting the difficulty of the situation acknowledges the patient's experience. The therapeutic statement validates feelings and supports continued sharing without judgment or directive language at any point in the encounter. Option d is incorrect because Asking about coping strategies is therapeutic and patient-centered. The question respects the patient's autonomy and encourages exploration of personal strengths and resources rather than directing or critici

Correct Answer: Sit quietly and provide a calm presence

Sitting quietly and providing a calm presence honors the patient's need to process the news. Therapeutic silence communicates support without pushing the patient to speak before being ready, and it deepens the nurse-patient relationship during the moment. Option a is incorrect because Filling silence with detailed explanation overwhelms a patient who is still absorbing news. The nurse should match the patient's emotional state and let pacing be guided by the patient rather than the nurse's discomfort. Option c is incorrect because Suggesting distractions like a movie minimizes the moment and shuts down emotional processing. The patient needs space to feel and think, not entertainment, especially right after learning of a serious diagnosis at the bedside. Option d is incorrect because Encouraging immediate decision making during raw grief is unwise. The patient needs time to process the news, and major choices are better made later when emotions have settled and the team

Correct Answer: Use a certified medical interpreter for accuracy

Using a certified medical interpreter ensures accurate communication and protects confidentiality. Family interpreters may misinterpret medical content or filter sensitive information, so the nurse arranges professional interpretation for clinical conversations whenever language barriers exist. Option a is incorrect because Speaking louder in English does not improve understanding for a patient who does not speak the language. Volume is not the issue, and the practice can also feel disrespectful or intimidating to the patient. Option b is incorrect because Skipping the topic to save time leaves important information unshared. The patient deserves the same level of explanation as any other patient, and language differences cannot become a reason for unequal care here. Option c is incorrect because Asking the housekeeper to interpret breaches confidentiality and risks inaccuracy. The interpreter must be certified for medical work, and informal interpreters often miss medical detail or ma

Correct Answer: Use simple words, allow questions, include parents

Simple language, opportunities for questions, and inclusion of parents support school-aged children. The child develops trust through honest age-appropriate communication, and the parents reinforce understanding during and after the conversation as the procedure approaches. Option a is incorrect because Complex medical terminology overwhelms a school-aged child. The level of language must match the child's developmental stage, with simple direct words and concrete examples to help the child grasp what will happen. Option b is incorrect because Speaking only to the parents and excluding the child is disrespectful and unhelpful. The child experiences the procedure firsthand, and exclusion from the conversation increases fear and reduces the chance of cooperation in the moment. Option d is incorrect because Telling the child that the procedure will not hurt sets up broken trust if there is any discomfort. Honest age-appropriate descriptions, including expected sensations, help the ch

Correct Answer: Ask patient to explain in own words

Asking the patient to explain in their own words confirms understanding through teach-back. The nurse identifies misunderstandings, corrects them, and reinforces the teaching, which improves retention and adherence to the plan after discharge. Option b is incorrect because Asking if the patient understands often produces a polite yes regardless of true comprehension. The closed question does not test understanding, and the nurse should use teach-back instead to check learning more accurately. Option c is incorrect because Having the patient sign that teaching occurred documents the activity but does not confirm understanding. The signature is a record, not an assessment of comprehension, and the nurse must use teach-back to check learning. Option d is incorrect because Reading the instructions out loud once delivers information but does not confirm understanding. The nurse must check whether the patient absorbed and can apply the content, which requires the active teach-back process du

Correct Answer: Address emotional needs and revisit teaching later

Addressing emotional needs first and revisiting teaching when the patient is more ready respects readiness to learn. The nurse builds rapport, listens to concerns, and resumes teaching when the patient can focus on the material effectively. Option a is incorrect because Forcing teaching to follow the schedule ignores the patient's current state. Teaching at the wrong moment misses retention and frustrates the patient, so flexibility based on readiness is part of effective patient education here. Option b is incorrect because Skipping emotional processing and presenting facts produces poor retention. Patients in distress often cannot absorb content, and the nurse should support emotions before resuming the cognitive teaching about the diagnosis and management. Option c is incorrect because Planning a long detailed lecture immediately is unsuitable for a tearful distracted patient. Short focused sessions with frequent check-ins work better, and the timing should match the patient�

Correct Answer: Demonstrate skill, allow practice with feedback

Demonstration paired with return demonstration and feedback fits a kinesthetic and visual learner. The patient watches, practices, and receives immediate correction, which supports skill acquisition and confidence in performing the technique at home reliably. Option a is incorrect because Using only written pamphlets without demonstration ignores the patient's preferred style. Reading alone may not support a learner who needs to see and try the skill, so written material works better as a supplement. Option b is incorrect because Lecturing for thirty minutes without practice does not match the preferred kinesthetic style. The patient needs hands-on practice with feedback rather than long verbal information, which can be hard to retain without active application here. Option d is incorrect because Skipping demonstration and relying on memorization fails the preferred learning style. The patient may not be able to perform the skill correctly without seeing and trying it, so the tech

Correct Answer: Speak clearly, face patient, large-print materials

Speaking clearly, facing the patient for lip reading, and using large-print materials supports older adults with hearing impairment. The nurse also reduces background noise, breaks information into chunks, and uses teach-back to confirm understanding. Option b is incorrect because Speaking softly with a fast pace is hard for any older adult to follow, especially with hearing impairment. The technique reduces understanding rather than supporting it, so the approach must use clear pace and adequate volume. Option c is incorrect because Skipping handouts to save time eliminates a useful reinforcement tool for older adults. Written materials help patients review information at home, and large print or simple language supports those with sensory or cognitive change. Option d is incorrect because Using technical jargon with quick speech overwhelms older adults learning new content. The nurse should use plain language, slow pacing, and pauses to allow processing during teaching about new diag

Correct Answer: Focus on medications, warning signs, follow-up

Focusing on medications, warning signs to watch for, and follow-up appointments covers the survival skills needed at home. The nurse uses teach-back to confirm understanding and provides written reinforcement for review after discharge. Option a is incorrect because Covering every detail of every condition is unrealistic in the time available. The patient cannot retain that much new information, and the nurse risks losing focus on the most important survival skills for safety. Option c is incorrect because Skipping all teaching and discharging fast leaves the patient unprepared and unsafe. Discharge teaching is a fundamental nursing responsibility, and rushing it can lead to readmission or adverse events at home. Option d is incorrect because Teaching only hobbies and lifestyle additions ignores the urgent priority of medications and warning signs. The patient needs survival skills first, and lifestyle topics can come later through outpatient follow-up and additional resources at home.

Correct Answer: Take routine vital signs on stable patient

Routine vital signs on a stable patient fit within unlicensed assistive personnel scope. The task is predictable and does not require nursing judgment, so the nurse can delegate safely while remaining responsible for any abnormal findings reported. Option a is incorrect because An admission assessment requires registered nurse-level skills, including history, physical assessment, and care planning. The complexity exceeds unlicensed assistive personnel scope, and the registered nurse retains responsibility for that initial baseline evaluation. Option b is incorrect because Initiating intravenous fluids requires a licensed nurse and falls outside unlicensed assistive personnel scope. The skill involves judgment about access, fluid choice, and rate, none of which can be performed by unlicensed staff. Option c is incorrect because Teaching insulin self-injection is a registered nurse responsibility because it requires assessment of learning, return demonstration, and clinical judgment. Unl

Correct Answer: Right task, circumstance, person, direction, supervision

The five rights of delegation are right task, right circumstance, right person, right direction, and right supervision. The framework guides the nurse in deciding what to delegate, to whom, and how to monitor outcomes during the shift. Option a is incorrect because Demographics like age and gender are not the five rights of delegation. The framework focuses on task, circumstance, person, direction, and supervision rather than patient identifiers used in medication administration or care planning. Option b is incorrect because Location-based items like unit, room, and floor are not the five rights of delegation. The framework concerns the delegation process itself, not the geographic placement of the patient or the staff during care. Option d is incorrect because Schedule, hand off, report, lab, and fluid are not the five rights of delegation. The actual framework names the elements that help the nurse decide whether and how to delegate a particular task each time.

Correct Answer: Administer routine oral meds to stable patient

Administering routine oral medications to a stable patient fits licensed practical nurse scope in most states. The nurse confirms the assignment is appropriate for the patient's condition and remains available for questions during the shift. Option b is incorrect because Developing a complete admission care plan is generally a registered nurse responsibility. The licensed practical nurse contributes to the plan, but the registered nurse synthesizes the assessment data and creates the overall plan as required. Option c is incorrect because Conducting a complex initial admission assessment is typically a registered nurse role. The licensed practical nurse may collect data but does not perform the comprehensive judgment-based assessment required at admission for new patients. Option d is incorrect because Adjusting the care plan based on initial assessment is registered nurse work. The licensed practical nurse implements the plan and reports findings, but plan revision requires the r

Correct Answer: Initial admission assessment with complex judgment

Initial admission assessment with complex judgment is a registered nurse responsibility. The task involves history, physical assessment, and the formation of an initial care plan, all of which require registered nurse-level scope and decision making. Option a is incorrect because Routine vital signs on a stable patient can be delegated to unlicensed assistive personnel. The task is predictable and does not require complex judgment, making it appropriate for delegation under the five rights framework. Option b is incorrect because Helping with bathing for a stable patient is also delegable. The task fits within unlicensed assistive personnel scope and does not require nursing judgment, so the nurse can assign it during the shift. Option c is incorrect because Walking a stable patient down the hallway is delegable to unlicensed assistive personnel. The activity is routine and predictable, with the registered nurse remaining available to evaluate any change in the patient's condition

Correct Answer: Reassume direct nursing responsibility for the patient

When a patient becomes unstable, the registered nurse reassumes direct responsibility and may pull back tasks previously delegated. The nurse remains at the bedside, performs direct assessment, and coordinates the team for rapid evaluation and intervention. Option a is incorrect because Continuing all delegations as previously planned ignores the change in patient status. The new situation calls for closer registered nurse involvement, and tasks that fit before may not fit during the unstable period. Option b is incorrect because Delegating even more tasks for efficiency is unsafe in a deteriorating patient. The nurse must increase, not decrease, direct involvement, and pulling tasks back lets the nurse focus on the patient's care. Option d is incorrect because Avoiding the patient further is unethical and unsafe. The nurse should be at the bedside, performing direct assessment, communicating with the team, and ensuring rapid response to the developing clinical change at the momen