G
Terms in this set (75)
HESI
HESI - Fundamentals exam with question and answer 100%
A+
When turning an immobile bedridden client B
without assistance, which action by the Rationale: Because the nurse can only stand on one side
of nurse best ensures client safety? the bed, bed rails should be up on the opposite side
to
A. Securely grasp the client's arm and leg. ensure that the client does not fall out of bed. Option A can
B.Put bed rails up on the side of bed cause client injury to the skin or joint. Options C and D are
opposite from the nurse. useful techniques while turning a client but have less priority
C. Correctly position and use a turn sheet. in terms of safety than use of the bed rails.
D.Lower the head of the client's bed slowly.
,The nurse identifies a potential for infection B
in a client with partial-thickness (second- Rationale: Careful handwashing technique is the single most
degree) and full-thickness (third-degree) effective intervention for the prevention of contamination
to burns. What intervention has the highest all clients. Option A reverses the hypovolemia that initially
priority in decreasing the client's risk of accompanies burn trauma but is not related to decreasing
the infection? proliferation of infective organisms. Options C and D are
A. Administration of plasma expanders recommended by various burn centers as possible ways to
B.Use of careful handwashing technique reduce the chance of infection. Option B is a proven
C. Application of a topical antibacterial technique to prevent
infection. cream
D.Limiting visitors to the client with burns
The nurse is aware that malnutrition is a A
common problem among clients served by Rationale: Long-term protein deficiency is required to cause
a community health clinic for the homeless. significantly lowered serum albumin levels. Albumin is made
Which laboratory value is the most reliable by the liver only when adequate amounts of amino acids
(from indicator of chronic protein malnutrition? protein breakdown) are available. Albumin has a long
half-life,
A. Low serum albumin level so acute protein loss does not significantly alter serum levels.
B.Low serum transferrin level Option B is a serum protein with a half-life of only 8 to 10 days,
C. High hemoglobin level so it will drop with an acute protein deficiency. Options C and
D.High cholesterol level D are not clinical measures of protein malnutrition.
In completing a client's preoperative C
routine, the nurse finds that the operative Rationale: The surgeon should be informed immediately
that permit is not signed. The client begins to ask the permit is not signed. It is the surgeon's
responsibility to more questions about the surgical explain the procedure to the client and obtain
the client's
procedure. Which action should the nurse signature on the permit. Although the nurse can witness an
take next? operative permit, the procedure must first be explained by
the
A. Witness the client's signature to the health care provider or surgeon, including answering the
permit. client's questions. The client's questions should be addressed
B. Answer the client's
questions about the before the permit is
signed. surgery.
C. Inform the surgeon that the operative
permit is not signed and the client
has questions about the surgery.
D.Reassure the client that the surgeon will
answer any questions before the
anesthesia is administered.
The nurse is assessing several clients prior B
to surgery. Which factor in a client's history Rationale:
poses the greatest threat for complications Anticoagulants increase the risk for bleeding during
surgery, to occur during surgery? which can pose a threat for the development of surgical
A. Taking birth control pills for the past 2 complications. The health care provider should be
informed years that the client is taking these drugs. Although clients who
take
B. Taking anticoagulants for the past year birth control
pills may be more susceptible to the
C. Recently completing antibiotic therapy development of thrombi, such problems usually occur
D.Having taken laxatives PRN for the last 6 postoperatively. A client with option C or D is at less of
a months surgical risk than with option B.
, When assisting a client from the bed to a B
chair, which procedure is best for the nurse Rationale: Option B describes the correct positioning of the
to follow? nurse and affords the nurse a wide base of support
while
A. Place the chair parallel to the bed, with its stabilizing the client's knees when assisting to a
standing back toward the head of the bed and assistposition. The chair should be placed at a 45-degree
angle to the client in moving to the chair. the bed, with the back of the chair toward the head of
the
B.With the nurse's feet spread apart and bed. Clients should never be lifted under the axillae;
this knees aligned with the client's knees, stand could damage nerves and strain the nurse's back.
The client and pivot the client into the chair. should be instructed to use the arms of the chair and
should
C. Assist the client to a standing position by never place his or her arms around the nurse's neck;
this gently lifting upward, underneath the axillae. places undue stress on the nurse's neck and
back and
D.Stand beside the client, place the client's increases the risk for a
fall. arms around the nurse's neck, and gently
move the client to the chair.
Which step(s) should the nurse take when A, B
administering ear drops to an adult client? Rationale: The correct answers (A and B) are the appropriate
(Select all that apply.) administration of ear drops. The dropper should be held 1
cm
A. Place the client in a side-lying position. (½ inch) above the ear canal (C). A cotton ball should be
B.Pull the auricle upward and outward. placed in the outermost canal (D). The auricle is pulled down
C. Hold the dropper 6 cm above the ear and back for a child younger than 3 years of age, but not
an canal. adult (E).
D.Place a cotton ball into the inner canal.
E. Pull the auricle down and back.
The nurse is instructing a client in the proper B
use of a metered-dose inhaler. Which Rationale: The medication should be inhaled through the
instruction should the nurse provide the mouth simultaneously with compression of the inhaler. This will
client to ensure the optimal benefits from facilitate the desired destination of the aerosol
medication
the drug? deep in the lungs for an optimal bronchodilation effect.
A. "Fill your lungs with air through your Options A, C, and D do not allow for deep lung penetration.
mouth and then compress the inhaler."
B."Compress the inhaler while
slowly breathing in through your
mouth."
C. "Compress the inhaler while inhaling
quickly through your nose."
D."Exhale completely after compressing
the inhaler and then inhale."
Terms in this set (75)
HESI
HESI - Fundamentals exam with question and answer 100%
A+
When turning an immobile bedridden client B
without assistance, which action by the Rationale: Because the nurse can only stand on one side
of nurse best ensures client safety? the bed, bed rails should be up on the opposite side
to
A. Securely grasp the client's arm and leg. ensure that the client does not fall out of bed. Option A can
B.Put bed rails up on the side of bed cause client injury to the skin or joint. Options C and D are
opposite from the nurse. useful techniques while turning a client but have less priority
C. Correctly position and use a turn sheet. in terms of safety than use of the bed rails.
D.Lower the head of the client's bed slowly.
,The nurse identifies a potential for infection B
in a client with partial-thickness (second- Rationale: Careful handwashing technique is the single most
degree) and full-thickness (third-degree) effective intervention for the prevention of contamination
to burns. What intervention has the highest all clients. Option A reverses the hypovolemia that initially
priority in decreasing the client's risk of accompanies burn trauma but is not related to decreasing
the infection? proliferation of infective organisms. Options C and D are
A. Administration of plasma expanders recommended by various burn centers as possible ways to
B.Use of careful handwashing technique reduce the chance of infection. Option B is a proven
C. Application of a topical antibacterial technique to prevent
infection. cream
D.Limiting visitors to the client with burns
The nurse is aware that malnutrition is a A
common problem among clients served by Rationale: Long-term protein deficiency is required to cause
a community health clinic for the homeless. significantly lowered serum albumin levels. Albumin is made
Which laboratory value is the most reliable by the liver only when adequate amounts of amino acids
(from indicator of chronic protein malnutrition? protein breakdown) are available. Albumin has a long
half-life,
A. Low serum albumin level so acute protein loss does not significantly alter serum levels.
B.Low serum transferrin level Option B is a serum protein with a half-life of only 8 to 10 days,
C. High hemoglobin level so it will drop with an acute protein deficiency. Options C and
D.High cholesterol level D are not clinical measures of protein malnutrition.
In completing a client's preoperative C
routine, the nurse finds that the operative Rationale: The surgeon should be informed immediately
that permit is not signed. The client begins to ask the permit is not signed. It is the surgeon's
responsibility to more questions about the surgical explain the procedure to the client and obtain
the client's
procedure. Which action should the nurse signature on the permit. Although the nurse can witness an
take next? operative permit, the procedure must first be explained by
the
A. Witness the client's signature to the health care provider or surgeon, including answering the
permit. client's questions. The client's questions should be addressed
B. Answer the client's
questions about the before the permit is
signed. surgery.
C. Inform the surgeon that the operative
permit is not signed and the client
has questions about the surgery.
D.Reassure the client that the surgeon will
answer any questions before the
anesthesia is administered.
The nurse is assessing several clients prior B
to surgery. Which factor in a client's history Rationale:
poses the greatest threat for complications Anticoagulants increase the risk for bleeding during
surgery, to occur during surgery? which can pose a threat for the development of surgical
A. Taking birth control pills for the past 2 complications. The health care provider should be
informed years that the client is taking these drugs. Although clients who
take
B. Taking anticoagulants for the past year birth control
pills may be more susceptible to the
C. Recently completing antibiotic therapy development of thrombi, such problems usually occur
D.Having taken laxatives PRN for the last 6 postoperatively. A client with option C or D is at less of
a months surgical risk than with option B.
, When assisting a client from the bed to a B
chair, which procedure is best for the nurse Rationale: Option B describes the correct positioning of the
to follow? nurse and affords the nurse a wide base of support
while
A. Place the chair parallel to the bed, with its stabilizing the client's knees when assisting to a
standing back toward the head of the bed and assistposition. The chair should be placed at a 45-degree
angle to the client in moving to the chair. the bed, with the back of the chair toward the head of
the
B.With the nurse's feet spread apart and bed. Clients should never be lifted under the axillae;
this knees aligned with the client's knees, stand could damage nerves and strain the nurse's back.
The client and pivot the client into the chair. should be instructed to use the arms of the chair and
should
C. Assist the client to a standing position by never place his or her arms around the nurse's neck;
this gently lifting upward, underneath the axillae. places undue stress on the nurse's neck and
back and
D.Stand beside the client, place the client's increases the risk for a
fall. arms around the nurse's neck, and gently
move the client to the chair.
Which step(s) should the nurse take when A, B
administering ear drops to an adult client? Rationale: The correct answers (A and B) are the appropriate
(Select all that apply.) administration of ear drops. The dropper should be held 1
cm
A. Place the client in a side-lying position. (½ inch) above the ear canal (C). A cotton ball should be
B.Pull the auricle upward and outward. placed in the outermost canal (D). The auricle is pulled down
C. Hold the dropper 6 cm above the ear and back for a child younger than 3 years of age, but not
an canal. adult (E).
D.Place a cotton ball into the inner canal.
E. Pull the auricle down and back.
The nurse is instructing a client in the proper B
use of a metered-dose inhaler. Which Rationale: The medication should be inhaled through the
instruction should the nurse provide the mouth simultaneously with compression of the inhaler. This will
client to ensure the optimal benefits from facilitate the desired destination of the aerosol
medication
the drug? deep in the lungs for an optimal bronchodilation effect.
A. "Fill your lungs with air through your Options A, C, and D do not allow for deep lung penetration.
mouth and then compress the inhaler."
B."Compress the inhaler while
slowly breathing in through your
mouth."
C. "Compress the inhaler while inhaling
quickly through your nose."
D."Exhale completely after compressing
the inhaler and then inhale."
