HESI RN FUNDAMENTALS EXAM | 3 VERSIONS
COMBINED WITH VERIFIED SOLUTIONS/A+ GRADE
The nurse is called to the waiting room of a pediatric clinic. The
frantic mother states, "I think my 4-month-old baby is choking!"
What steps will the nurse take? (Select all that apply.)
A.
Compress the chest once between the nipples with two fingers.
B.
Note any obstruction or absence of breathing.
C.
Deliver five backslaps between the shoulder blades.
D.
Place the infant over the nurse's arm.
E.
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Perform a blind finger sweep. .....ANSWER.....B, C, D
Rationale: The fingers are placed at the same location on an
infant as chest compressions for CPR; however, the nurse must
deliver five chest thrusts, after the five back slaps. Blind sweeps
are not used as this action may push the object deeper into the
throat. The remaining steps are correct.
Which fluid will the nurse select to administer with the prescribed
blood transfusion?
A.
5% Dextrose and water
B.
Normal saline
C.
Lactated Ringers solution
D.
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5% Dextrose and lactated ringers .....ANSWER.....B
Rationale: Normal saline solution is the only solution that is
compatible with blood.
When assisting a client from the bed to a chair, which procedure
is best for the nurse to follow?
A.
Place the chair parallel to the bed, with its back toward the
head of the bed and assist the client in moving to the chair.
B.
With the nurse's feet spread apart and knees aligned with the
client's knees, stand and pivot the client into the chair.
C.
Assist the client to a standing position by gently lifting upward,
underneath the axillae.
D.
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Stand beside the client, place the client's arms around the nurse's
neck, and gently move the client to the chair. .....ANSWER.....B
Rationale: Option B describes the correct positioning of the nurse
and affords the nurse a wide base of support while stabilizing
the client's knees when assisting to a standing position. The chair
should be placed at a 45-degree angle to the bed, with the
back of the chair toward the head of the bed. Clients should
never be lifted under the axillae; this could damage nerves and
strain the nurse's back. The client should be instructed to use the
arms of the chair and should never place his or her arms around
the nurse's neck; this places undue stress on the nurse's neck and
back and increases the risk for a fall.
How many mL will the nurse document on the client's intake and
output record from the items listed? _____ mL
1200 mL water
4 ounce container of gelatin