1|Page
Community HESI Study Guide|
comprehensive Q&A for certification
success
Transfusion reaction -correct-answer-Interventions: stop the transfusion, infuse
normal saline at a keep-vein-open rate to maintain a patent IV access line and
maintain the client's intravascular volume.
Hand restraints -correct-answer-When used, the skin integrity, neurovascular, and
circulatory status of the extremity should be checked every 30 minutes. Devices
should be removed every 2 hours to permit muscle exercise and to promote
circulation.
Snake bite -correct-answer-Priority interventions: the first priority is to move the
victim to a safe area away from the snake and encourage the victim to rest to
decrease venom circulation. Next, jewelry and constricting clothing are removed
before swelling occurs. Immobilizing the extremity and maintaining the extremity
below heart level would be done next; these actions limit the spread of the
venom. The victim is kept warm and calm. Stimulants such as alcohol or
caffeinated beverages are not given to the victim because these products may
speed the absorption of the venom. The victim should be transported to an
emergency facility as soon as is possible.
,2|Page
Voluntary admission client -correct-answer-Voluntary clients have the right to
demand and obtain release. The nurse needs to be familiar with the state and
facility policies and procedures. The best nursing action is to contact the HCP, who
has the authority to discuss discharge with the client. Many states require that the
client submit a written release notice to the facility staff members, who reevaluate
the client's condition for possible conversion to involuntary status if necessary,
according to criteria established by law. While this is a possibility, it should not be
used as a threat to the client.
Client secrets -correct-answer-The nurse should never promise to keep a secret.
Secrets are never appropriate in a therapeutic relationship. The nurse needs to be
honest and tell the client that a promise cannot be made to keep the secret.
Involuntarily committed clients -correct-answer-Clients who are admitted
involuntarily do not lose their right to informed consent. Clients must be
considered legally competent until they have been declared incompetent through
a legal proceeding. The best determination for the nurse to make is to obtain the
informed consent from the client.
Good Samaritan Law -correct-answer-A law that is passed by a state legislature to
encourage nurses and other HCPs to provide care to a person when an accident,
emergency, or injury occurs without fear of being sued for the care provided. Its
protection lies in the inability to sue the nurse or other HCP for negligence in the
,3|Page
care provided at the scene of the accident or during the emergency, even if
further injury occurred because of the HCP's care. Called immunity from suit, this
protection usually applies only if all the conditions of the law are met, such as that
the HCP received no compensation for the care provided and the care given was
not willfully and wantonly negligent.
Room assignment for autistic child -correct-answer-Autistic disorder is a complex
childhood disorder that involves abnormalities in behavior, social interactions, and
communication. Autistic children are unable to relate to persons or respond to
social and emotional cues. Characteristically these children engage in repetitive
behaviors, including head banging, twirling in circles, biting themselves, and
flapping their hands or arms. Abnormal communication patterns include verbal
and nonverbal communication. A child with autism needs decreased stimulation,
with limited visual and auditory distractions. A private room would be the best
environment, allowing for control of visual and auditory distractions.
Case management -correct-answer-Case management represents an
interdisciplinary health care delivery system to promote appropriate use of
hospital personnel and material resources; its aim is to maximize hospital
revenues while providing for optimal outcomes of care. Case management
manages client care by managing the client care environment.
Activation of the agency disaster plan -correct-answer-In an external disaster
many people may be brought to the emergency department for treatment. The
initial nursing action must be to activate the disaster plan.
, 4|Page
Nurse as a client advocate -correct-answer-A person who speaks out for or
supports the best interests of the client. This includes promoting client comfort,
questioning health care provider prescriptions, supporting a client decision
regarding health care choices, encouraging independence in addition to speaking
for the client. Consists of nursing actions that inform, support and affirm clients in
their goal of self-determination (client independence).
Case manager -correct-answer-As a nurse, this role is to organize, manage, and
balance health care services needed for the client.
Administration of enemas "until they are clear" -correct-answer-If administering
enemas until clear is prescribed on the morning of the test, enemas should be
administered no more than three times. The continuous administration of enemas
may cause fluid and electrolyte disturbances and imbalances.
Continuous Passive Motion Machine -correct-answer-With its use, the leg should
be kept in a neutral position and not rotated either internally or externally. The
knee should be positioned at the hinge joint of the machine. The nurse should
monitor for pressure areas at the knee and the groin and should follow the HCP's
prescriptions and institutional protocol regarding extension and flexion and the
speed of the CPM machine.
Community HESI Study Guide|
comprehensive Q&A for certification
success
Transfusion reaction -correct-answer-Interventions: stop the transfusion, infuse
normal saline at a keep-vein-open rate to maintain a patent IV access line and
maintain the client's intravascular volume.
Hand restraints -correct-answer-When used, the skin integrity, neurovascular, and
circulatory status of the extremity should be checked every 30 minutes. Devices
should be removed every 2 hours to permit muscle exercise and to promote
circulation.
Snake bite -correct-answer-Priority interventions: the first priority is to move the
victim to a safe area away from the snake and encourage the victim to rest to
decrease venom circulation. Next, jewelry and constricting clothing are removed
before swelling occurs. Immobilizing the extremity and maintaining the extremity
below heart level would be done next; these actions limit the spread of the
venom. The victim is kept warm and calm. Stimulants such as alcohol or
caffeinated beverages are not given to the victim because these products may
speed the absorption of the venom. The victim should be transported to an
emergency facility as soon as is possible.
,2|Page
Voluntary admission client -correct-answer-Voluntary clients have the right to
demand and obtain release. The nurse needs to be familiar with the state and
facility policies and procedures. The best nursing action is to contact the HCP, who
has the authority to discuss discharge with the client. Many states require that the
client submit a written release notice to the facility staff members, who reevaluate
the client's condition for possible conversion to involuntary status if necessary,
according to criteria established by law. While this is a possibility, it should not be
used as a threat to the client.
Client secrets -correct-answer-The nurse should never promise to keep a secret.
Secrets are never appropriate in a therapeutic relationship. The nurse needs to be
honest and tell the client that a promise cannot be made to keep the secret.
Involuntarily committed clients -correct-answer-Clients who are admitted
involuntarily do not lose their right to informed consent. Clients must be
considered legally competent until they have been declared incompetent through
a legal proceeding. The best determination for the nurse to make is to obtain the
informed consent from the client.
Good Samaritan Law -correct-answer-A law that is passed by a state legislature to
encourage nurses and other HCPs to provide care to a person when an accident,
emergency, or injury occurs without fear of being sued for the care provided. Its
protection lies in the inability to sue the nurse or other HCP for negligence in the
,3|Page
care provided at the scene of the accident or during the emergency, even if
further injury occurred because of the HCP's care. Called immunity from suit, this
protection usually applies only if all the conditions of the law are met, such as that
the HCP received no compensation for the care provided and the care given was
not willfully and wantonly negligent.
Room assignment for autistic child -correct-answer-Autistic disorder is a complex
childhood disorder that involves abnormalities in behavior, social interactions, and
communication. Autistic children are unable to relate to persons or respond to
social and emotional cues. Characteristically these children engage in repetitive
behaviors, including head banging, twirling in circles, biting themselves, and
flapping their hands or arms. Abnormal communication patterns include verbal
and nonverbal communication. A child with autism needs decreased stimulation,
with limited visual and auditory distractions. A private room would be the best
environment, allowing for control of visual and auditory distractions.
Case management -correct-answer-Case management represents an
interdisciplinary health care delivery system to promote appropriate use of
hospital personnel and material resources; its aim is to maximize hospital
revenues while providing for optimal outcomes of care. Case management
manages client care by managing the client care environment.
Activation of the agency disaster plan -correct-answer-In an external disaster
many people may be brought to the emergency department for treatment. The
initial nursing action must be to activate the disaster plan.
, 4|Page
Nurse as a client advocate -correct-answer-A person who speaks out for or
supports the best interests of the client. This includes promoting client comfort,
questioning health care provider prescriptions, supporting a client decision
regarding health care choices, encouraging independence in addition to speaking
for the client. Consists of nursing actions that inform, support and affirm clients in
their goal of self-determination (client independence).
Case manager -correct-answer-As a nurse, this role is to organize, manage, and
balance health care services needed for the client.
Administration of enemas "until they are clear" -correct-answer-If administering
enemas until clear is prescribed on the morning of the test, enemas should be
administered no more than three times. The continuous administration of enemas
may cause fluid and electrolyte disturbances and imbalances.
Continuous Passive Motion Machine -correct-answer-With its use, the leg should
be kept in a neutral position and not rotated either internally or externally. The
knee should be positioned at the hinge joint of the machine. The nurse should
monitor for pressure areas at the knee and the groin and should follow the HCP's
prescriptions and institutional protocol regarding extension and flexion and the
speed of the CPM machine.
