• HESI AA3 Entrance Exam 2024/2025
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Rationale: Deflating the cuff for 30 to 60 seconds allows blood
flow to return to the extremity so that an accurate reading can
be obtained on that extremity a second time. Option A could
result in a falsely high reading. Option B reduces circulation,
causes pain, and could alter the reading. Option D is not an
accurate method of assessing blood pressure.
The nurse is obtaining a lie-sit-stand blood pressure reading on
a client. Which action is most important for the nurse to take
for this client?
A.
Stay with the client while the client is standing.
B.
Record the findings on the graphic sheet in the chart.
C.
Keep the blood pressure cuff on the same arm.
D.
,Record changes in the client's pulse rate.
<<<100%Correctanswers>>A
The nurse is called to the waiting room of a pediatric clinic. The
frantic mother states, "I think my 4-month-old baby is choking!"
What steps will the nurse take? (Select all that apply.)
A.
Compress the chest once between the nipples with two fingers.
B.
Note any obstruction or absence of breathing.
C.
Deliver five backslaps between the shoulder blades.
D.
Place the infant over the nurse's arm.
E.
Perform a blind finger sweep. <<<100%Correctanswers>>B,
C, D
Rationale: The fingers are placed at the same location on an
infant as chest compressions for CPR; however, the nurse must
deliver five chest thrusts, after the five back slaps. Blind sweeps
,are not used as this action may push the object deeper into the
throat. The remaining steps are correct.
Which fluid will the nurse select to administer with the
prescribed blood transfusion?
A.
5% Dextrose and water
B.
Normal saline
C.
Lactated Ringers solution
D.
5% Dextrose and lactated ringers
<<<100%Correctanswers>>B
Rationale: Normal saline solution is the only solution that is
compatible with blood.
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.
<<<100%Correctanswers>>B
Rationale: Option 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.
Clients should never be lifted under the axillae; 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; this places undue
stress on the nurse's neck and back and increases the risk for a
fall.
latest update
Rationale: Deflating the cuff for 30 to 60 seconds allows blood
flow to return to the extremity so that an accurate reading can
be obtained on that extremity a second time. Option A could
result in a falsely high reading. Option B reduces circulation,
causes pain, and could alter the reading. Option D is not an
accurate method of assessing blood pressure.
The nurse is obtaining a lie-sit-stand blood pressure reading on
a client. Which action is most important for the nurse to take
for this client?
A.
Stay with the client while the client is standing.
B.
Record the findings on the graphic sheet in the chart.
C.
Keep the blood pressure cuff on the same arm.
D.
,Record changes in the client's pulse rate.
<<<100%Correctanswers>>A
The nurse is called to the waiting room of a pediatric clinic. The
frantic mother states, "I think my 4-month-old baby is choking!"
What steps will the nurse take? (Select all that apply.)
A.
Compress the chest once between the nipples with two fingers.
B.
Note any obstruction or absence of breathing.
C.
Deliver five backslaps between the shoulder blades.
D.
Place the infant over the nurse's arm.
E.
Perform a blind finger sweep. <<<100%Correctanswers>>B,
C, D
Rationale: The fingers are placed at the same location on an
infant as chest compressions for CPR; however, the nurse must
deliver five chest thrusts, after the five back slaps. Blind sweeps
,are not used as this action may push the object deeper into the
throat. The remaining steps are correct.
Which fluid will the nurse select to administer with the
prescribed blood transfusion?
A.
5% Dextrose and water
B.
Normal saline
C.
Lactated Ringers solution
D.
5% Dextrose and lactated ringers
<<<100%Correctanswers>>B
Rationale: Normal saline solution is the only solution that is
compatible with blood.
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.
<<<100%Correctanswers>>B
Rationale: Option 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.
Clients should never be lifted under the axillae; 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; this places undue
stress on the nurse's neck and back and increases the risk for a
fall.
