BSN 225 HESI NURSING
FUNDAMENTALS EXAM
QUESTIONS AND ANSWERS QUICK
REVIEW
Droplet precautions - ANS ✓The top edge of a surgical face mask should be
secured over the bridge of the nose just below the eyeglasses to provide a
snugly- fitting mask that prevents transmission of pathogens while the client is
transported outside the room. Transporting the client without protective
equipment endangers other persons who might come in contact with the client.
A fitted respirator-style mask is not necessary unless the clients placed on
airborne precautions for tuberculosis. Protective goggles are used by caregivers
likely to be in contact with potentially contaminated body fluids S do not need
to be worn by the client.
confused client- action - ANS ✓A confused client who is wandering is at risk for
injury. The nurse should orient the client to her surroundings, escort the client to
her room to promote sleep, S use a bed alarm to alert the nurse to further
wandering behavior.
, Korotkoff sound-immediate - ANS ✓Kortkoff sounds describe blood
pressure from the first sound, which is a clear, rhythmic, tapping sound that
corresponds with systolic blood pressure, to the 5th sound which is a
disappearance of all sound S corresponds with diastolic blood pressure. If the
1st kortkoff sound is heard immediately after releasing the valve, it means that
the cuff was not inflated high enough S all the air should be released S the cuff
reflated to a higher level.
Cyanosis- respiration rate - ANS ✓Cyanosis, a bluish discoloration, is
an indication of hypoxemia, so it is most important for the nurse to assess
the client's respiratory function first, followed by the remaining vital
signs.
Oxygenation - ANS ✓Low O2 levels may cause confusion and combativeness,
sot he highest priority is assessment of peripheral O2 saturation, which evaluates
FUNDAMENTALS EXAM
QUESTIONS AND ANSWERS QUICK
REVIEW
Droplet precautions - ANS ✓The top edge of a surgical face mask should be
secured over the bridge of the nose just below the eyeglasses to provide a
snugly- fitting mask that prevents transmission of pathogens while the client is
transported outside the room. Transporting the client without protective
equipment endangers other persons who might come in contact with the client.
A fitted respirator-style mask is not necessary unless the clients placed on
airborne precautions for tuberculosis. Protective goggles are used by caregivers
likely to be in contact with potentially contaminated body fluids S do not need
to be worn by the client.
confused client- action - ANS ✓A confused client who is wandering is at risk for
injury. The nurse should orient the client to her surroundings, escort the client to
her room to promote sleep, S use a bed alarm to alert the nurse to further
wandering behavior.
, Korotkoff sound-immediate - ANS ✓Kortkoff sounds describe blood
pressure from the first sound, which is a clear, rhythmic, tapping sound that
corresponds with systolic blood pressure, to the 5th sound which is a
disappearance of all sound S corresponds with diastolic blood pressure. If the
1st kortkoff sound is heard immediately after releasing the valve, it means that
the cuff was not inflated high enough S all the air should be released S the cuff
reflated to a higher level.
Cyanosis- respiration rate - ANS ✓Cyanosis, a bluish discoloration, is
an indication of hypoxemia, so it is most important for the nurse to assess
the client's respiratory function first, followed by the remaining vital
signs.
Oxygenation - ANS ✓Low O2 levels may cause confusion and combativeness,
sot he highest priority is assessment of peripheral O2 saturation, which evaluates
