HESI RN FUNDAMENTALS EXAM With Rationales 2020/2021

HESI RN FUNDAMENTALS1.When turning an immobile bedridden client without assistance, which actionby 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 whileturning 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 expandersB.Use of careful handwashing techniqueC.Application of a topical antibacterial creamD.Limiting visitors to the client with burnsRationale: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.