HESI – Fundamentals With CORRECT
SOLUTIONS
When ,turning ,an ,immobile ,bedridden ,client ,without ,assistance, ,which ,action ,by ,the ,nurse ,best ,ensu
res ,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. ,- ,(correct ,answer) ,-B
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 ,t
he ,skin ,or ,joint. ,Options ,C ,and ,D ,are ,useful ,techniques ,while ,turning ,a ,client ,but ,have ,less ,priority ,i
n ,terms ,of ,safety ,than ,use ,of ,the ,bed ,rails.
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 ,- ,(correct ,answer) ,-B
Rationale: ,Careful ,handwashing ,technique ,is ,the ,single ,most ,effective ,intervention ,for ,the ,preventio
n ,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.
,The ,nurse ,is ,aware ,that ,malnutrition ,is ,a ,common ,problem ,among ,clients ,served ,by ,a ,community ,h
ealth ,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 ,- ,(correct ,answer) ,-A
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 ,cl
inical ,measures ,of ,protein ,malnutrition.
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 ,nurs
e ,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 ,th
e ,surgery.
D. ,Reassure ,the ,client ,that ,the ,surgeon ,will ,answer ,any ,questions ,before ,the ,anesthesia ,is ,administe
red. ,- ,(correct ,answer) ,-C
Rationale: ,The ,surgeon ,should ,be ,informed ,immediately ,that ,the ,permit ,is ,not ,signed. ,It ,is ,the ,surge
on's ,responsibility ,to ,explain ,the ,procedure ,to ,the ,client ,and ,obtain ,the ,client's ,signature ,on ,the ,per
mit. ,Although ,the ,nurse ,can ,witness ,an ,operative ,permit, ,the ,procedure ,must ,first ,be ,explained ,by ,t
he ,health ,care ,provider ,or ,surgeon, ,including ,answering ,the ,client's ,questions. ,The ,client's ,questions
,should ,be ,addressed ,before ,the ,permit ,is ,signed.
The ,nurse ,is ,assessing ,several ,clients ,prior ,to ,surgery. ,Which ,factor ,in ,a ,client's ,history ,poses ,the ,gr
eatest ,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 ,- ,(correct ,answer) ,-B
Rationale:
Anticoagulants ,increase ,the ,risk ,for ,bleeding ,during ,surgery, ,which ,can ,pose ,a ,threat ,for ,the ,develo
pment ,of ,surgical ,complications. ,The ,health ,care ,provider ,should ,be ,informed ,that ,the ,client ,is ,takin
g ,these ,drugs. ,Although ,clients ,who ,take ,birth ,control ,pills ,may ,be ,more ,susceptible ,to ,the ,develop
ment ,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.
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 ,clie
nt ,to ,the ,chair. ,- ,(correct ,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 ,nev
er ,be ,lifted ,under ,the ,axillae; ,this ,could ,damage ,nerves ,and ,strain ,the ,nurse's ,back. ,The ,client ,shoul
d ,be ,instructed ,to ,use ,the ,arms ,of ,the ,chair ,and ,should ,never ,place ,his ,or ,her ,arms ,around ,the ,nur
se's ,neck; ,this ,places ,undue ,stress ,on ,the ,nurse's ,neck ,and ,back ,and ,increases ,the ,risk ,for ,a ,fall.
Which ,step(s) ,should ,the ,nurse ,take ,when ,administering ,ear ,drops ,to ,an ,adult ,client? ,(Select ,all ,that
,apply.)
A. ,Place ,the ,client ,in ,a ,side-lying ,position.
B. ,Pull ,the ,auricle ,upward ,and ,outward.
C. ,Hold ,the ,dropper ,6 ,cm ,above ,the ,ear ,canal.
D. ,Place ,a ,cotton ,ball ,into ,the ,inner ,canal.
E. ,Pull ,the ,auricle ,down ,and ,back. ,- ,(correct ,answer) ,-A, ,B