FOUNDATION HESI
(QUESTION &
ANSWERS) TEST
BANK 2023/2024
update
The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which
documentation should the nurse use to identify placement of the IV access?
A.Left brachial vein
B.Right cephalic vein
C.Dorsal side of the right wrist
D.Right upper extremity
Rationale: The cephalic vein is large and superficial and identifies the anatomic name of the vein that is accessed, which should be included in the documentation (B). The basilic vein of the arm is used for IV access, not the brachial vein (A), which is too deep to be accessed for IV infusion. Although veins on the dorsal side of the right wrist (C) are visible, they are fragile and using them would be painful, so they are not recommended for IV access. (D) is not specific enough for documenting the location of the IV access.
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.Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.
Rationale:
(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 (A). Clients should never be lifted under the axillae (C); 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 (D); this places undue stress on
the nurse's neck and back and increases the risk for a fall.
The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home?
A.
Determine how the client feels about changing the dressing.
B.
Ask the client to describe the procedure in writing.
C. Seek a family member's evaluation of the client's ability to change the dressing.
D.
Observe the client change the dressing unassisted.
Rationale:
Observing the client directly (D) will allow the nurse to determine if mastery of the skill has
been obtained and provide an opportunity to affirm the skill. (A) may be therapeutic but will not provide an opportunity to evaluate the client's ability to perform the procedure. (B) may be threatening to an older client and will not determine his ability. (C) is not as effective as direct observation by the nurse.
A female nurse is assigned to care for a close friend, who says, "I am worried that friends will find out about my diagnosis." The nurse tells her friend that legally she must protect a client's confidentiality. Which resource describes the nurse's legal responsibilities?
A.
Code of Ethics for Nurses
B.
State Nurse Practice Act
C.
Patient's Bill of Rights
D.
ANA Standards of Practice
Rationale:
The State Nurse Practice Act (B) contains legal requirements for the protection of client confidentiality and the consequences for breaches in confidentiality. (A) outlines ethical standards for nursing care but does not include legal guidelines. (C and D) describe expectations for nursing practice but do not address legal implications.
One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a female client tells the nurse, "I think I will plan a big party for all my friends." How should the nurse respond?
A. "You may not have enough energy before long to hold a big party."
B.
"Do you mean to say that you want to plan your funeral and wake?"
C.
"Planning a party and thinking about all your friends sounds like fun."
D.
"You should be thinking about spending your last days with your family."
Rationale:
Setting goals that bring pleasure are appropriate and should be encouraged by the nurse (C) as long as the nurse does not perpetuate a client's denial. (A) is a negative response, implying that the client should not plan a party. (B) puts words in the client's mouth that may not be accurate. The nurse should support the client's goals rather than telling the client how to spend her time (D).
After a needlestick occurs while removing the cap from a sterile needle, which action should the nurse implement?
A.
Complete an incident report.
B.
Select another sterile needle.
C.
Disinfect the needle with an alcohol swab.
D.
Notify the supervisor of the department immediately.
Rationale:
After a needlestick, the needle is considered used, so the nurse should discard it and select another needle (B). Because the needle was sterile when the nurse was stuck and the needle was not in contact with any other person's body fluids, the nurse does not need to complete an incident report (A) or notify the occupational health nurse (D). Disinfecting a needle with an alcohol swab (C) is not in accordance with standards for safe practice and infection control.
(QUESTION &
ANSWERS) TEST
BANK 2023/2024
update
The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which
documentation should the nurse use to identify placement of the IV access?
A.Left brachial vein
B.Right cephalic vein
C.Dorsal side of the right wrist
D.Right upper extremity
Rationale: The cephalic vein is large and superficial and identifies the anatomic name of the vein that is accessed, which should be included in the documentation (B). The basilic vein of the arm is used for IV access, not the brachial vein (A), which is too deep to be accessed for IV infusion. Although veins on the dorsal side of the right wrist (C) are visible, they are fragile and using them would be painful, so they are not recommended for IV access. (D) is not specific enough for documenting the location of the IV access.
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.Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.
Rationale:
(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 (A). Clients should never be lifted under the axillae (C); 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 (D); this places undue stress on
the nurse's neck and back and increases the risk for a fall.
The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home?
A.
Determine how the client feels about changing the dressing.
B.
Ask the client to describe the procedure in writing.
C. Seek a family member's evaluation of the client's ability to change the dressing.
D.
Observe the client change the dressing unassisted.
Rationale:
Observing the client directly (D) will allow the nurse to determine if mastery of the skill has
been obtained and provide an opportunity to affirm the skill. (A) may be therapeutic but will not provide an opportunity to evaluate the client's ability to perform the procedure. (B) may be threatening to an older client and will not determine his ability. (C) is not as effective as direct observation by the nurse.
A female nurse is assigned to care for a close friend, who says, "I am worried that friends will find out about my diagnosis." The nurse tells her friend that legally she must protect a client's confidentiality. Which resource describes the nurse's legal responsibilities?
A.
Code of Ethics for Nurses
B.
State Nurse Practice Act
C.
Patient's Bill of Rights
D.
ANA Standards of Practice
Rationale:
The State Nurse Practice Act (B) contains legal requirements for the protection of client confidentiality and the consequences for breaches in confidentiality. (A) outlines ethical standards for nursing care but does not include legal guidelines. (C and D) describe expectations for nursing practice but do not address legal implications.
One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a female client tells the nurse, "I think I will plan a big party for all my friends." How should the nurse respond?
A. "You may not have enough energy before long to hold a big party."
B.
"Do you mean to say that you want to plan your funeral and wake?"
C.
"Planning a party and thinking about all your friends sounds like fun."
D.
"You should be thinking about spending your last days with your family."
Rationale:
Setting goals that bring pleasure are appropriate and should be encouraged by the nurse (C) as long as the nurse does not perpetuate a client's denial. (A) is a negative response, implying that the client should not plan a party. (B) puts words in the client's mouth that may not be accurate. The nurse should support the client's goals rather than telling the client how to spend her time (D).
After a needlestick occurs while removing the cap from a sterile needle, which action should the nurse implement?
A.
Complete an incident report.
B.
Select another sterile needle.
C.
Disinfect the needle with an alcohol swab.
D.
Notify the supervisor of the department immediately.
Rationale:
After a needlestick, the needle is considered used, so the nurse should discard it and select another needle (B). Because the needle was sterile when the nurse was stuck and the needle was not in contact with any other person's body fluids, the nurse does not need to complete an incident report (A) or notify the occupational health nurse (D). Disinfecting a needle with an alcohol swab (C) is not in accordance with standards for safe practice and infection control.
