Fundamentals HESI Exam 2
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A client with pneumonia has a decrease in oxygen saturation
from 94% to 88% while ambulating. Based on these findings,
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which intervention should the nurse implement first?
Assist the ambulating client back to the bed.
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Encourage the client to ambulate to resolve pneumonia.
Obtain a prescription for portable oxygen while ambulating.
Move the oximetry probe from the finger to the earlobe. Ans:
A
An oxygen saturation below 90% indicates inadequate
oxygenation. First, the client should be assisted to return to
bed to minimize oxygen demands. Ambulation increases
aeration of the lungs to prevent pooling of respiratory
secretions, but the client's activity at this time is depleting
oxygen saturation of the blood. Increased activity increases
respiratory effort, and oxygen may be necessary to continue
ambulation, but first the client should return to bed to rest.
On admission, a client presents a signed living will that
includes a Do Not Resuscitate (DNR) prescription. When the
client stops breathing, the nurse performs cardiopulmonary
resuscitation (CPR) and successfully revives the client. What
legal issues could be brought against the nurse?
, 2
Assault.
Battery.
Malpractice.
False imprisonment. Ans: B
Civil laws protect individual rights and include intentional
torts, such as assault (an intentional threat to engage in
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harmful contact with another) or battery (unwanted
touching).Performing any procedure against the client's wishes
can potentially create a legal issue, such as battery, even if the
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procedure is of questionable benefit to the client.
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The nurse plans to obtain health assessment information from
a primary source. Which option is a primary source for the
completion of the health assessment?
Client.
Healthcare provider.
A family member.
Previous medical records. Ans: A
A primary source of information for a health assessment is the
client. Family members, the medical record, and the healthcare
provider are considered secondary sources about the client's
health history, but other details, such as subjective data, can
only be provided directly from the client.
, 3
The nurse is teaching a client with numerous allergies how to
avoid allergens. Which instruction should be included in this
teaching plan?
Avoid any types of sprays, powders, and perfumes.
Wearing a mask while cleaning will not help to avoid allergens.
Purchase any type of clothing, but be sure it is washed before
wearing it.
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Pollen count is related to hay fever, not to allergens. Ans: A
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The client with allergies should be instructed to reduce any
exposure to pollen, dust, fumes, odors, sprays, powders, and
perfumes. The client should be encouraged to wear a mask
when working around dust or pollen. Clients with allergies
should avoid any clothing that causes itching; washing clothes
will not prevent an allergic reaction to some fabrics. Pollen
count is related to allergens, and the client should be
instructed to stay indoors when the pollen count is high.
A client with pericardial effusion has phrenic nerve
compression resulting in recurrent hiccups. The healthcare
provider prescribes metoclopramide (Reglan) liquid 10 mg PO
q 6 hours. Reglan is available as 5 mg/5 ml. A measuring
device marked in teaspoons is being used. How many
teaspoons should the nurse administer? Ans: 2
First, using the formula, Desired dose/dose on Hand x
Quantity of volume on hand (D/H x Q),
10 mg / 5 mg x 5ml = 10 ml
Next using the known conversion of 5 ml = 1 tsp:
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5 ml : 1 tsp :: 10 ml : X
: 1 / X
5X = 10
X=2
The unlicensed assistive personnel (UAP) working on a chronic
neuro unit asks the nurse to help determine the safest way to
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transfer an older client with left-sided weakness from the bed
to the chair. Which method describes the correct transfer
procedure for this client?
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Place the chair at a right angle to the bed on the client's left
side before moving.
Assist the client to a standing position, then place the right
hand on the armrest.
Have the client place the left foot next to the chair and pivot to
the left before sitting.
Move the chair parallel to the right side of the bed, and stand
the client on the right foot. Ans: D
When positioning a client for transfer from bed to chair when
the client has left-sided weakness, use the client's stronger
side, the right side, for weight-bearing during the transfer. In
this case, the client should stand on the right foot during the
transfer.
The nurse observes an unlicensed assistive personnel (UAP)
checking a client's blood pressure with a cuff that is too small,
but the blood pressure reading obtained is within the client's