WGU D450 HEALTH HESI EVALUATION EXAMS
QUESTIONS AND ANSWERS SET A+
✔✔Snake bite - ✔✔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.
✔✔Voluntary admission client - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 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 - ✔✔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 - ✔✔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 - ✔✔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.
✔✔Nurse as a client advocate - ✔✔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 - ✔✔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" - ✔✔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 - ✔✔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.
✔✔Cushing's syndrome - ✔✔A condition caused by excessive amounts of cortisol.
✔✔Positive variance - ✔✔Occurs when the client achieves maximum benefits and is
discharged earlier than anticipated on his or her critical path. Example: A postoperative
client is discharged home 1 day earlier than expected.
✔✔Steps in suctioning airway of tracheostomy tube - ✔✔1. Place client in semi-Fowler's
position.
2. Turn on the suction device and set the regulator at 80 mm Hg.
3. Apply gloves and attach the suction tubing to the suction catheter.
4. Hyperoxygenate the client.
5. Insert the catheter into the tracheostomy until resistance is met, and then pull it back
1 cm.
6. Apply intermittent suction and slowly withdraw the catheter while rotating it back and
forth.
✔✔Infiltration - ✔✔Signs & Symptoms: Blanching, coolness, and edema of the IV site.
Interventions: Remove IV catheter (priority) to prevent further damage. Warm
compresses may be applied to the area only after the IV catheter is removed and only if
the infiltrated solution is not damaging to the surrounding tissues. Measure the area of
infiltration after IV catheter removal to assess for any further tissue damage.
✔✔Discontinuation of tube feedings - ✔✔Nurse should verify authorization by the family
to discontinue the treatment is in place. Once the decision is made by the family, the
HCP writes the prescription.
✔✔Use of restraints - ✔✔Needs to be avoided if possible. If the nurse determines that a
restraint is necessary, this should be discussed with the family and a prescription needs
to be obtained from the HCP. The HCP's prescription protects the nurse from liability.
The nurse should explain to the client and family the reasons that the restraint is
necessary, the type of restraint selected, and the anticipated duration of restraint.
✔✔Epiglottitis - ✔✔When suspected, the priorities are to maintain a patent airway and
obtain a chest radiograph to confirm the diagnosis. If present, the child is taken promptly
to the operating room for tracheal intubation or immediate placement of a surgical
airway.
✔✔Role of caregiver - ✔✔Nurse choosing to perform basic nursing skills, such as vital
signs, completing admission assessment history, and assisting the client to change into
a hospital gown.
QUESTIONS AND ANSWERS SET A+
✔✔Snake bite - ✔✔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.
✔✔Voluntary admission client - ✔✔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 - ✔✔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 - ✔✔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 - ✔✔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 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 - ✔✔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 - ✔✔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 - ✔✔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.
✔✔Nurse as a client advocate - ✔✔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 - ✔✔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" - ✔✔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 - ✔✔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.
✔✔Cushing's syndrome - ✔✔A condition caused by excessive amounts of cortisol.
✔✔Positive variance - ✔✔Occurs when the client achieves maximum benefits and is
discharged earlier than anticipated on his or her critical path. Example: A postoperative
client is discharged home 1 day earlier than expected.
✔✔Steps in suctioning airway of tracheostomy tube - ✔✔1. Place client in semi-Fowler's
position.
2. Turn on the suction device and set the regulator at 80 mm Hg.
3. Apply gloves and attach the suction tubing to the suction catheter.
4. Hyperoxygenate the client.
5. Insert the catheter into the tracheostomy until resistance is met, and then pull it back
1 cm.
6. Apply intermittent suction and slowly withdraw the catheter while rotating it back and
forth.
✔✔Infiltration - ✔✔Signs & Symptoms: Blanching, coolness, and edema of the IV site.
Interventions: Remove IV catheter (priority) to prevent further damage. Warm
compresses may be applied to the area only after the IV catheter is removed and only if
the infiltrated solution is not damaging to the surrounding tissues. Measure the area of
infiltration after IV catheter removal to assess for any further tissue damage.
✔✔Discontinuation of tube feedings - ✔✔Nurse should verify authorization by the family
to discontinue the treatment is in place. Once the decision is made by the family, the
HCP writes the prescription.
✔✔Use of restraints - ✔✔Needs to be avoided if possible. If the nurse determines that a
restraint is necessary, this should be discussed with the family and a prescription needs
to be obtained from the HCP. The HCP's prescription protects the nurse from liability.
The nurse should explain to the client and family the reasons that the restraint is
necessary, the type of restraint selected, and the anticipated duration of restraint.
✔✔Epiglottitis - ✔✔When suspected, the priorities are to maintain a patent airway and
obtain a chest radiograph to confirm the diagnosis. If present, the child is taken promptly
to the operating room for tracheal intubation or immediate placement of a surgical
airway.
✔✔Role of caregiver - ✔✔Nurse choosing to perform basic nursing skills, such as vital
signs, completing admission assessment history, and assisting the client to change into
a hospital gown.
