,HESI RN FUNDAMENTALS QUESTIONS & ANSWERS
1. When turning an immobile bedridden client without assistance, which action
by the nurse best ensures client safety?
A. Securely grasp the client's arm and leg.
B. Put bed rails up on the side of bed opposite from
the nurse.
C. Correctly position and use a turn sheet.
D. Lower the head of the client's bed slowly.
Rationale:
Because the nurse can only stand on one side of the bed, bed rails should be up on
the opposite side to ensure that the client does not fall out of bed. Option A can
cause client injury to the skin or joint. Options C and D are useful techniques while
turning a client but have less priority in terms of safety than use of the bed rails.
2. The nurse identifies a potential for infection in a client with partial-thickness
(second-degree) and full-thickness (third-degree) burns. What intervention
has the highest priority in decreasing the client's risk of infection?
A. Administration of plasma expanders
B. Use of careful handwashing technique
C. Application of a topical antibacterial cream
D. Limiting visitors to the client with burns
Rationale:
Careful handwashing technique is the single most effective intervention for the
prevention of contamination to all clients. Option A reverses the hypovolemia that
initially accompanies burn trauma but is not related to decreasing the proliferation
of infective organisms. Options C and D are recommended by various burn centers
as possible ways to reduce the chance of infection. Option B is a proven technique
to prevent infection.
, 3. The nurse is aware that malnutrition is a common problem among clients
served by a community health clinic for the homeless. Which laboratory
value is the most reliable indicator of chronic protein malnutrition?
A. Low serum albumin level
B. Low serum transferrin level
C. High hemoglobin level
D. High cholesterol level
Rationale:
Long-term protein deficiency is required to cause significantly lowered serum
albumin levels. Albumin is made by the liver only when adequate amounts of
amino acids (from protein breakdown) are available. Albumin has a long half-life,
so acute protein loss does not significantly alter serum levels. Option B is a serum
protein with a half-life of only 8 to 10 days, so it will drop with an acute protein
deficiency. Options C and D are not clinical measures of protein malnutrition.
4. In completing a client's preoperative routine, the nurse finds that the
operative permit is not signed. The client begins to ask more questions about
the surgical procedure. Which action should the nurse take next?
A. Witness the client's signature to the permit.
B. Answer the client's questions about the 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.
Rationale:
The surgeon should be informed immediately that the permit is not signed. It is the
surgeon's responsibility to explain the procedure to the client and obtain the client's
signature on the permit. Although the nurse can witness an operative permit, the
procedure must first be explained by the health care provider or surgeon, including
answering the client's questions. The client's questions should be addressed before
the permit is signed.
, 5. The nurse is assessing several clients prior to surgery. Which factor in a
client's history poses the greatest threat for complications to occur during
surgery?
A. Taking birth control pills for the past 2 years
B. Taking anticoagulants for the past year
C. Recently completing antibiotic therapy
D. Having taken laxatives PRN for the last 6 months
Rationale:
Anticoagulants increase the risk for bleeding during surgery, which can pose a
threat for the development of surgical complications. The health care provider
should be informed that the client is taking these drugs. Although clients who take
birth control pills may be more susceptible to the development of thrombi, such
problems usually occur postoperatively. A client with option C or D is at less of a
surgical risk than with option B.
6. 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:
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
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