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2020 HESI 225

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Exam of 60 pages for the course 2020 Hesi 225 at 2020 Hesi 225 (2020 Hesi 225)

Institution
2020 Hesi 225
Course
2020 Hesi 225

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Definition



b. Reassess the client to determine the need for continuing
restraints.



Give this one a try later!



The nurse is providing wound care to a client with stage 3 pressure ulcer that has
a large amount of eschar. The wound care prescription states "clean the wound
and then apply collagenase." collagenase is a debriding agent. The prescription
does not specify a cleaning method. Which technique should the nurse cleanse
the pressure ulcer?
a. Lightly coat the wound with povidone-iodine solution
b. Irrigate the wound with sterile normal saline
c. Flush the wound with sterile hydrogen peroxide d. Remove the eschar with a
wet-to-dry dressing




The nurse is caring for a hospitalized client who was placed in restraints
due to confusion. The family removes the restraints while they are with the
client. When the family leaves, what action should the nurse take first?
a. Apply the restraints to maintain the client's safety.
b. Reassess the client to determine the need for continuing restraints.

, c. Document the time the family left and continue to monitor the client.
d. Call the healthcare provider for a new prescription.



.The nurse is teaching a client about use of the syringes and needles for home
administration of medications. Which action by the client indicates an
understanding of standard precaution?
a. Remove needle before discarding used syringes
b. Wear gloves to dispose of the needle and syringe
c. Done a face mask before administering the medication
d. Washes hands before handling the needle and syringe




The nurse in the emergency department observes a colleague viewing the
electronic health record (EHR) of a client who holds an elected position in the
community. The client is not a part of the colleague's assignment. Which action
should the nurse implement?
a. Communicate the colleague's actions to the unit charge nurse
b. Send an email to facility administration reporting the action
c. Write an anonymous complaint to a professional website
d. Post a comment about the action on a staff discussion board


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2 of 55

Definition



b. bend the arm by flexing the ulnar to the humerus



Give this one a try later!



The nurse is caring for a hospitalized client who was placed in restraints due to
confusion. The family removes the restraints while they are with the client. When
the family leaves, what action should the nurse take first?
a. Apply the restraints to maintain the client's safety.
b. Reassess the client to determine the need for continuing restraints.

,c. Document the time the family left and continue to monitor the client.
d. Call the healthcare provider for a new prescription.



The nurse is teaching a client how to do active range of motion (ROM)
exercises. To exercise the hinge joints, which action should the nurse
instruct the client to perform?
a. Tilt the pelvis forwards and backward
b. bend the arm by flexing the ulnar to the humerus
c. Turn the head to the right and left
d. Extend the arm at the ide and rotate in circles




The nurse is providing wound care to a client with stage 3 pressure ulcer that has
a large amount of eschar. The wound care prescription states "clean the wound
and then apply collagenase." collagenase is a debriding agent. The prescription
does not specify a cleaning method. Which technique should the nurse cleanse
the pressure ulcer?
a. Lightly coat the wound with povidone-iodine solution
b. Irrigate the wound with sterile normal saline
c. Flush the wound with sterile hydrogen peroxide d. Remove the eschar with a
wet-to-dry dressing




The nurse receives a report that a client with an indwelling urinary catheter has
an output of 150 mL, for the previous 6 hour shift. Which intervention should the
nurse implement first?
a. Check the drainage tubing for a kink
b. Review the intake and output record
c. Notify the healthcare provider
d. Give the client 8 oz of water to drink


Don't know?

, 3 of 55

Definition



0.8



Give this one a try later!



The nurse is teaching a client how to do active range of motion (ROM) exercises.
To exercise the hinge joints, which action should the nurse instruct the client to
perform?
a. Tilt the pelvis forwards and backward
b. bend the arm by flexing the ulnar to the humerus
c. Turn the head to the right and left
d. Extend the arm at the ide and rotate in circles




The nurse retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an
automated dispensing system, for a client who is receiving hydromorphone
3 mg IM 6 hours PRN severe pain. How many mL should the nurse
administer to the client? (Enter the numerical value only. If rounding is
required , round to the nearest tenth)




The nurse receives a report that a client with an indwelling urinary catheter has
an output of 150 mL, for the previous 6 hour shift. Which intervention should the
nurse implement first?
a. Check the drainage tubing for a kink
b. Review the intake and output record
c. Notify the healthcare provider
d. Give the client 8 oz of water to drink




.The nurse is teaching a client about use of the syringes and needles for home
administration of medications. Which action by the client indicates an
understanding of standard precaution?
a. Remove needle before discarding used syringes
b. Wear gloves to dispose of the needle and syringe

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Institution
2020 Hesi 225
Course
2020 Hesi 225

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Written in
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