FOUNDATION HESI[GREEN BOOK] WITH QUESTIONS AND WELL VERIFIED ANSWERS [GRADED A+]

FOUNDATION
HESI[GREEN BOOK] WITH
QUESTIONS AND WELL
VERIFIED ANSWERS
[GRADED A+]




The nurse selects the best site for insertion of an IV catheter in
the client's right arm. Which documentation should the nurse use
to identify placement of the IV access?


A.Left brachial vein
B.Right cephalic vein

,C.Dorsal side of the right wrist
D.Right upper extremity - ANS✔✔---B




Rationale:
The cephalic vein is large and superficial and identifies the
anatomic name of the vein that is accessed, which should be
included in the documentation (B). The basilic vein of the arm is
used for IV access, not the brachial vein (A), which is too deep to
be accessed for IV infusion. Although veins on the dorsal side of
the right wrist (C) are visible, they are fragile and using them
would be painful, so they are not recommended for IV access. (D)
is not specific enough for documenting the location of the IV
access.
When assisting a client from the bed to a chair, which procedure
is best for the nurse to follow?


A.Place the chair parallel to the bed, with its back toward the head
of the bed and assist the client in moving to the chair.


B.With the nurse's feet spread apart and knees aligned with the
client's knees, stand and pivot the client into the chair.


C.Assist the client to a standing position by gently lifting upward,
underneath the axillae.

,D.Stand beside the client, place the client's arms around the
nurse's neck, and gently move the client to the chair. -
ANS✔✔---B


Rationale:
(B) describes the correct positioning of the nurse and affords the
nurse a wide base of support while stabilizing the client's knees
when assisting to a standing position. The chair should be placed
at a 45-degree angle to the bed, with the back of the chair toward
the head of the bed (A). Clients should never be lifted under the
axillae (C); this could damage nerves and strain the nurse's back.
The client should be instructed to use the arms of the chair and
should never place his or her arms around the nurse's neck (D);
this places undue stress on the nurse's neck and back and
increases the risk for a fall.
The nurse is preparing an older client for discharge. Which
method is best for the nurse to use when evaluating the client's
ability to perform a dressing change at home?


A.


Determine how the client feels about changing the dressing.
B.


Ask the client to describe the procedure in writing.
C.

, Seek a family member's evaluation of the client's ability to change
the dressing.
D.


Observe the client change the dressing unassisted. - ANS✔✔--
-D


Rationale:
Observing the client directly (D) will allow the nurse to determine if
mastery of the skill has been obtained and provide an opportunity
to affirm the skill. (A) may be therapeutic but will not provide an
opportunity to evaluate the client's ability to perform the
procedure. (B) may be threatening to an older client and will not
determine his ability. (C) is not as effective as direct observation
by the nurse.
A female nurse is assigned to care for a close friend, who says, "I
am worried that friends will find out about my diagnosis." The
nurse tells her friend that legally she must protect a client's
confidentiality. Which resource describes the nurse's legal
responsibilities?


A.


Code of Ethics for Nurses
B.