2022/2023 Module 6 Exam_ HESI VN , HESI 101 Questions And Answers

7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 1 1 / 1 pts Which event would require a nurse to complete and file an incident report? A client has a seizure. The nurse determines that a client would benefit from the use of a walker to ambulate. The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion pump is not working. When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor’s blood pressure and takes the visitor to the emergency department for treatment. Correct! 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: An incident is any event that is not consistent with the routine operation of a health care unit or routine care of a client. Examples of incidents include client falls, needlestick injuries, a visitor having symptoms of illness, medication administration errors, accidental omission of prescribed therapies, and circumstances leading to injury or a risk for injury. An incident report does not need to be filed if a client has a seizure unless the client sustains injury as a result of the seizure. If the nurse determines that a client would benefit from the use of a walker to ambulate, he or she should take the appropriate action to obtain one. If the nurse notes that the battery of an intravenous infusion pump is not working, he or she should obtain a functioning pump and send the nonfunctioning pump to the appropriate department for repair. Test-Taking Strategy: Use knowledge of the subject, reasons for filing an incident report, to assist you with the process of elimination. Read each option carefully. Recalling that an incident is any event that is not consistent with the routine operation of a health care unit or routine care of a client will direct you to the correct option. Review the reasons for filing an incident report if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 2 1 / 1 pts A nurse, charting the administration of medications to an assigned client at 9 p.m., notes that atenolol (Tenormin) was prescribed to be administered at 9 a.m. instead of 9 p.m. The nurse checks the client’s vital signs, completes an incident report, and calls the health care provider to report the error. The health care provider tells the nurse that an incident report is not needed but instructs her to monitor the client during the night for hypotension. What action should the nurse take? 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Notifying the nursing supervisor Tearing up and discarding the incident report Telling the health care provider that the error warrants the completion of an incident report Correct! Telling the nursing supervisor that the health care provider did not want an incident report completed and filed Rationale: Incident reports are an important part of a health care agency’s quality improvement program. An incident is any event that is not consistent with the routine operation of a health care unit or routine care of a client. An example of an incident is administering a medication at a time at which it is not prescribed to be given. Whenever an incident occurs, an incident report is completed and filed in accordance with agency guidelines. The nursing supervisor would be notified of the incident; however, on the basis of the data in the question, the nurse should tell the health care provider that the error warrants completion and follow-through with an incident report. Therefore, the other options are incorrect. Test-Taking Strategy: Focus on the subject of the question, the health care provider’s telling the nurse that an incident report is not needed. Eliminate the comparable or alike options that involve notifying the nursing supervisor. To select from the remaining options, recall the purpose of an incident report to select the correct option. Review the procedures involved in completing and filing incident reports if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 3 1 / 1 pts 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Contact precautions are initiated for a client with methicillinresistant Staphylococcus aureus (MRSA) infection. The nurse, providing instructions to a nursing assistant about caring for the client, tells the assistant to take which action? To transfer the client to a semiprivate room That gloves only are needed to care for the client To wear gloves and a gown when changing the client’s bed linen Correct! To wear a gown when caring for the client and remove the gown immediately after leaving the client s room Rationale: Contact precautions require the use of gloves, gown, and goggles if direct client contact is anticipated. The client should be placed in a private room or, if a private room is not available, in a semiprivate room with another client who has active infection with the same microorganism but no other infection. The nursing assistant would remove the protective gear before leaving the client’s room. Test-Taking Strategy: Use the process of elimination. Eliminate the option that includes the closed-ended word “only.” Next eliminate the option that involves removal of the gown after leaving the client’s room. To select from the remaining options, read each carefully and visualize the procedure instituted for contact precautions, which will direct you to the correct option. If you had difficulty with this question, review contact precautions. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management Question 4 1 / 1 pts 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) The mother of a 3-year-old calls a neighbor who is a nurse and reports that her child just drank some window cleaner that had been stored in a cabinet. The nurse should instruct the mother to immediately take which action? Correct! Call a poison control center. Administer an excessive amount of fluids to induce vomiting. Call an ambulance to bring the child to the emergency department. Leave a message at the health care provider answering service about the incident. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: When a poisoning occurs, a poison center should be called immediately. Vomiting should not be induced if the victim is unconscious or if the substance ingested was a strong corrosive or petroleum product. Also, vomiting should not be induced unless a health care provider has given specific instructions to induce vomiting. Neither calling an ambulance nor calling the health care provider’s answering service is the immediate action, because either would delay treatment. Additionally, the health care provider would immediately make a referral to the poison control center. The poison control center may advise the mother to bring the child to the emergency department; if this is the case, the mother should then call an ambulance. Test-Taking Strategy: Note the strategic word “immediately” in the query of the question. First, recalling that vomiting should not be induced without appropriate advice to do so will help you eliminate the option that involves inducing vomiting. Next eliminate the comparable or alike options that will delay treatment (i.e., calling an ambulance and leaving a message with the answering service). Review immediate poison control measures if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Question 5 1 / 1 pts A hurricane is forecast to make landfall in 48 hours, and the staff of the emergency department of an area hospital is advised to prepare for casualties. Which action should the nurse who receives the telephone call regarding this warning take first? Correct! Activating the agency disaster plan Supplying the triage rooms with additional equipment 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Increasing the number of nursing staff for the day on which the hurricane is expected Calling the hospital maintenance department to secure the building against the storm Rationale: In an external disaster, many people may be brought to the emergency department for treatment. Although increasing the nursing staff and supplying the triage rooms with additional equipment may be steps in preparing for casualties, the initial action by the nurse manager must be activation of the disaster plan. Calling the hospital maintenance department to secure the building from the storm is not a responsibility that falls within the scope of nursing management. Test-Taking Strategy: Note the strategic word “first” in the query of the question. Use the process of elimination in determining the priority action. Note that the correct option is the umbrella option. Also remember that other necessary activities will be initiated once the agency disaster plan has been activated. Review procedures related to management in times of disaster if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Disasters Question 6 1 / 1 pts A home health nurse has instructed a client about safety measures during the use of an oxygen concentrator in the home. Which statements by the client indicate to the nurse that the client has understood the directions? Select all that apply. Correct! “I need to follow the oxygen prescription exactly.” 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “I can use my electric razor while I’m using oxygen.” “I have to keep the oxygen concentrator out of direct sunlight.” Correct! “I need to keep the oxygen concentrator as close to the wall as possible or put it in a corner.” “I have to tell everyone that they can’t smoke or have an open flame within 10 feet of the oxygen concentrator.” Correct! Rationale: The client should follow the oxygen prescription exactly. The use of electric razors or other equipment that could emit sparks should be avoided while oxygen is in use, because fire and injury to the client could result. The oxygen concentrator is kept out of direct sunlight and slightly away from walls and corners to permit adequate air flow. The client should not allow smoking or any type of flame within 10 feet of the oxygen source. Other measures include having telephone numbers for the health care provider, nurse, and oxygen vendor available and teaching the client signs and symptoms requiring emergency care. Test-Taking Strategy: Recall knowledge of the subject, oxygen safety measures, to assist you with eliminating options. Recall that one hazard associated with oxygen is ignition, which could result from heat in the form of flames or sparks. Evaluating the question from this perspective, eliminate the options that are unsafe. Review oxygen safety measures if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Safety Question 7 1 / 1 pts 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) A nurse is providing instructions to a nursing student who will be caring for a client in hand restraints. The nurse instructs the nursing student to release the restraints to permit muscle exercise how frequently? Correct! Every 2 hours Every 3 hours Every 4 hours Every 30 minutes Rationale: The nurse should assess the restraints and the client’s circulatory status and skin integrity every 30 minutes. Restraints must be released at least every 2 hours to permit muscle exercise and promote circulation. Agency guidelines regarding the use of restraints should always be followed. Test-Taking Strategy: Knowledge regarding the subject, the use of restraints, is necessary to answer this question. Noting the strategic words “release the restraints” will help direct you to the correct option. Review nursing responsibilities regarding the use of restraints if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Question 8 1 / 1 pts A community health nurse working in a school setting is concerned because parents are not participating in health activities designed to promote child safety. In this situation, which is the most appropriate initial action? 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Implementing a child safety program Planning a focused child safety program Performing an analysis of health problems related to child safety Determining the appropriateness of the planned health activity Correct! Rationale: In this situation, the best initial action would be to determine the appropriateness of the planned health activities. This would be followed by analysis, planning, and implementation. Test-Taking Strategy: Use the steps of the nursing process to answer the question. Note that the correct option involves the process of data collection, the first step of the nursing process. Review the procedure for planning health activities to provide safety if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Question 9 1 / 1 pts The nurse administers a dose of ramipril 2.5 mg to a client at 9 a.m. While documenting administration of the medication, the nurse discovers that 1.25 mg, not 2.5 mg, was the prescribed dose. The nurse assesses the client, completes an incident report, and notifies the health care provider and nursing supervisor of the error. What statement does the nurse add to the client’s record? An incident report was completed and filed. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Correct! Ramipril (Altace) 2.5 mg was administered at 9 a.m. Twice the amount of the prescribed ramipril was administered at 9 a.m. Client’s blood pressure was 128/82 mm Hg after the administration of the incorrect dose of ramipril. Rationale: After an incident, the nurse would document a concise and objective description of what occurred and any follow-up actions taken in the client’s record. The nurse would not document in the client’s record that an incident report was completed. Nor would the nurse document that twice the prescribed dose was given or that an incorrect dose was given. Test-Taking Strategy: Focus on the data in the question. Recall that notes made in a client’s record must be objective. Eliminate the comparable or alike options that indicate that an incorrect dose of medication was administered. Next note that the correct option clearly and accurately describes the incident in an objective manner. Review documentation of a medication error or other incident if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Ethical/Legal Question 10 1 / 1 pts A home health nurse has been called to the home of an older postoperative cardiovascular client by the client’s son. The son tells the nurse, “We’re using a hospital bed here at home, but my mother has fallen out of bed three times.” Which observation by the nurse reflects an increased risk of this client’s falling out of bed? 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) The client’s bed is in a low position. The client is oriented to person, place, and time. The caregiver uses the overbed table for feedings. The caregiver leaves both siderails down while the client is in bed. Correct! Rationale: Leaving the siderails of older client’s bed down may increase the client’s risk of falling. The aging process also increases this client’s potential for falls; therefore, evaluating the safety of the environment is a necessity. Keeping the client’s bed in a low position, orientating the client to the environment, and using the overbed table for feedings are all ways to help ensure the client’s safety. Test-Taking Strategy: Use the process of elimination, focusing on the subject, an observation of an unsafe practice. Noting that the question indicates that the bed is in the low position and that the client is oriented will assist you in eliminating these options. To select from the remaining options, choose the one that identifies an unsafe practice. Review the causes of falls in an older client if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Data Collection Content Area: Safety Ques 1 / 1 pts tion 11 A community health nurse is providing information to local residents about the transmission of anthrax. Through which body systems does the nurse tell the residents that anthrax can be contracted? Select all that apply. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Correct! Skin Correct! Lungs Immune Urinary Lymphatic Correct! Gastrointestinal Rationale: Anthrax, caused by Bacillus anthracis, can be contracted through the gastrointestinal system, abrasions in the skin, or inhalation. It is not contracted through the immune system, urinary tract, or lymphatic system. Test-Taking Strategy: Specific knowledge of the subject, the routes of infection with B. anthracis, is needed to answer this question. Remember that anthrax can be contracted through the gastrointestinal system, skin, or lungs. Review content on anthrax and its modes of transmission if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Biological/chemical warfare Question 12 1 / 1 pts A nurse is removing a partially empty chemotherapy infusion bag that was used to administer to a client with a diagnosis of Hodgkin disease. Which precaution should the nurse take while working with this intravenous (IV) infusion? Wearing gloves and a mask 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Wearing gloves and a gown Correct! Wearing gloves, a mask, and eye protection Wearing gloves, a mask, and a head covering Rationale: When handling chemotherapeutic agents, the nurse should wear disposable latex gloves, a mask that covers the nose and mouth, and eye protection, especially if a biological hood is not available. Wearing gloves and a mask or gloves and a gown will not provide adequate protection. A head covering is not necessary. Test-Taking Strategy: Knowledge regarding the subject, precautions for handling chemotherapeutic agents, is necessary to answer this question. Think about the effects and cytotoxic nature of chemotherapy to answer the question. Select the option that will provide the greatest degree of protection to the nurse handling chemotherapeutic agents. If you had difficulty with this question, review the precautions for handling a chemotherapy infusion. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Question 13 1 / 1 pts A nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the IV tubing port to the solution bag, the tubing drops, hitting the top of the medication cart. Which action should the nurse take to maintain asepsis? Correct! Obtaining new IV tubing Obtaining a new IV solution bag 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Scrubbing the tubing port with an alcohol swab Wiping the tubing port with povidone-iodine solution (Betadine) Rationale: If IV tubing becomes contaminated as a result of coming into contact with some nonsterile object, the nurse should obtain new IV tubing. Contaminated tubing could cause systemic infection in the client. The IV solution bag has not been contaminated and does not need replacement. Wiping the tubing port with Betadine or scrubbing it with alcohol is insufficient and would be contraindicated regardless, because the tubing will be attached directly to a catheter in the client’s vein. Test-Taking Strategy: Visualize the situation as you read the question. Use your knowledge of the subject, basic infection control measures and IV therapy, to answer this question. Also, focus on the data in the question and note that the IV tubing has become contaminated. Review aseptic technique if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control Ques 0 / 1 pts tion 14 A home health nurse is visiting a client with tuberculosis (TB). Which action by the client tells the nurse that the client understands the necessary infection control precautions to be taken at home? You Answered Staying secluded in the bedroom Wearing an oxygen mask at all times 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Keeping the house closed up to minimize the spread of disease Disposing of contaminated tissues in a container with a leakproof bag Correct Answer Rationale: The client under infection control precautions at home does not need to remain secluded; the client would not be at home if he or she were infectious. However, proper respiratory precautions are necessary. The house should be properly ventilated, and the windows should be opened as much as possible. Wearing an oxygen mask at all times is not a respiratory precaution, and there is no information in the question to indicate that oxygen is necessary. Contaminated tissues should be discarded in container with a leak-proof bag and then placed in an outdoor trash bin. Tissues should not be left lying around. Test-Taking Strategy: Use the process of elimination. Focus on the client’s diagnosis and the subject, infection control precautions at home. Recalling the mode of transmission and home care measures for TB will direct you to the correct option. Also note the words “secluded,” “all times,” and “closed up” in the incorrect options. If you had difficulty answering this question, review the precautions that should be taken by the client with TB who has been discharged home. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Infection Control Question 15 1 / 1 pts A home health nurse teaches a client about home modifications to reduce the risk of falls. Which statements by the client indicate a need for further teaching? Select all that apply. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “I need to use nightlights.” Correct! “I need to remove my wall-to-wall carpeting.” “I need to get handrails put up in the bathroom.” “I need to use the staircase handrails when I go up the stairs.” “I should walk barefoot as much as possible so that I’ll know about any wet spots on the floor.” Correct! Rationale: Home modifications to reduce the risk of falls include ensuring ample lighting, removing scatter rugs, placing handrails in bathrooms, and using handrails on all staircases. The client should wear flat rubber-soled shoes to prevent slips and falls. Walking barefoot will not reduce the risk of injury; in fact, it could actually increase the risk of foot injury and of slipping and falling. Removal of wallto-wall carpeting is not necessary. Test-Taking Strategy: Note the strategic words “need for further teaching.” These words indicate a negative event query and the need to select the incorrect options. Answer this question by eliminating the options that involve providing physical support for the client and that you know are needed in this situation (e.g., nightlights, handrails). Review home care measures to ensure safety and prevent falls if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Ques 1 / 1 pts tion 16 A nurse caring for a client who is under airborne precautions notes that the client is scheduled for a nuclear scan. Which action on the part of the nurse is appropriate? 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Planning to have the nuclear scan performed at the bedside Asking the technicians in the nuclear scan department to wear masks Placing a HEPA mask on the client for transport and for contact with other individuals Correct! Calling the nuclear medicine department and telling the technician that the test will have to be delayed until airborne precautions have been discontinued Rationale: If the client is under airborne precautions, client movement and transport should be limited as much as possible. If transport or movement is necessary, the nurse can minimize the dispersal of droplet nuclei from the client by placing a HEPA mask on the client. Having the scan performed at the bedside is not feasible. Asking the technicians in the nuclear medicine department to wear masks would not prevent the dispersal of airborne nuclei from the client. The health care provider is the individual who would prescribe the cancellation or delay of a diagnostic test. Additionally, delaying the test until airborne precautions have been discontinued is not within the role of the nurse. Test-Taking Strategy: Use the process of elimination and focus on the subject of the question, airborne precautions. Knowing that a nurse should not delay a prescribed test will help you eliminate this option. Eliminate the option of having the scan at the bedside because this action is unreasonable. To select from the remaining options, recall the route and mode of transmission of an airborne infection. This should direct you to the correct option. Review airborne precautions if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 17 1 / 1 pts A nurse employed in a health care provider’s office hears a client in the waiting room call out, “Help! Fire!” The nurse rushes to the waiting room and finds that the wastebasket is on fire. The nurse immediately takes which action? Confines the fire Extinguishes the fire Activates the fire alarm Correct! Removes the clients from the waiting room Rationale: The immediate priority in the event of a fire is removing any clients in immediate danger. The next step is activating the fire alarm. The nurse would then confine the fire by closing all of the doors and, finally, extinguish the fire. Test-Taking Strategy: Use knowledge of the subject, fire safety, to assist you with this question. Remember the mnemonic RACE to prioritize actions in the event of a fire: Rescue clients in immediate danger, sound the alarm, confine the fire by closing all doors, and extinguish. If you had difficulty with this question, review the principles of fire safety. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Question 18 1 / 1 pts 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) A nurse enters the laundry room to empty a bag of dirty linen and discovers a fire in a laundry basket. What action should the nurse take first? Confining the fire Extinguishing the fire Correct! Activating the fire alarm Running for the fire extinguisher Rationale: The immediate priority in the event of a fire is rescuing the clients in immediate danger. In this situation, no clients are in immediate danger. The next step is to activate the fire alarm. The nurse then confines the fire by closing all doors and, finally, extinguishes the fire. Test-Taking Strategy: Use knowledge of the subject, fire safety, to assist you with this question. Use the mnemonic RACE to remember priorities in the event of a fire: rescueclients in immediate danger, sound the alarm, confine the fire by closing all doors, and extinguish. If you had difficulty with this question, review the principles of fire safety. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Question 19 1 / 1 pts The safety department is providing a yearly educational session on fire safety and the use of fire extinguishers. A nurse is asked to demonstrate the use of a fire extinguisher after the session. The nurse demonstrates appropriate use of the fire extinguisher by first taking which action? 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Aiming at the base of the fire Correct! Pulling the pin on the fire extinguisher Squeezing the handle of the extinguisher Sweeping from the top to the bottom of the fire with the extinguisher Rationale: To use a fire extinguisher, pull the pin first. Next, aim the extinguisher at the base of the fire. Squeeze the handle of the extinguisher, then extinguish the fire by sweeping from side to side to coat the area evenly. Test-Taking Strategy: Use knowledge of the subject, fire safety, to assist you with this question. Use the mnemonic PASS to remember the steps in the use of a fire extinguisher: Pull the pin, aim at the base of the fire, squeeze the handle, and sweep from side to side to coat the area evenly. If you had difficulty with this question, review the appropriate use of a fire extinguisher. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Ques 1 / 1 pts tion 20 A nurse provides instruction to a new nurse employee regarding the application of a restraint to a client. The nurse watches as the nurse employee applies the restraint. What observation tells the nurse that the nurse employee is using correct procedure? The employee applies a tie knot in the restraint strap. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) The employee attaches the restraint straps securely to the siderails. The employee applies the restraint so that the strap does not tighten when force is applied against it. Correct! The employee secures the restraint in such a way that it is impossible to slip a finger between the restraint and the client’s skin. Rationale: A half-bow or safety knot should be used to apply a restraint, because it does not tighten when force is applied against it and because it allows quick, easy removal of the restraint in the event of an emergency. The restraint strap is secured to the bed frame, never to the side rails, to help prevent accidental injury in the event that the siderail is released. A restraint should be secured in such a way that one or two fingers can be easily slipped between the restraint and the client’s skin. Test-Taking Strategy: Note the strategic words “correct procedure” in the query. This indicates that you are looking for an option that involves an accurate measure of how a restraint is applied. Use the process of elimination and your knowledge of safety measures and the use of restraints to answer the question. Noting the words “tie knot,” “siderails,” and “impossible to slip” will assist you in eliminating these options. Review guidelines for the application of restraints if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management Question 21 1 / 1 pts 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) A nurse is instructing a group of nursing assistants in the principles of body mechanics. Which observations tell the nurse that a nursing assistant is using the principles appropriately? Select all that apply. The assistant leans forward when turning a client in bed. The assistant positions a box that is to be lifted between his knees. Correct! The assistant turns his back to change position while moving a client. The assistant keeps the object to be moved as close to his body as possible. Correct! The assistant helps a client requiring total care into a chair without additional assistance. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: When moving an object, the nursing assistant should position the object between his knees. The assistant should keep the client or object to be moved as close to his body as possible. When turning a client, the assistant should keep his back straight and take small steps with the feet. The assistant should turn his feet, rather than twisting his back, if a change in direction is necessary when carrying an object or a client. The assistant should seek out assistance when transferring a client who requires total care. Test-Taking Strategy: Use the process of elimination and your knowledge of the subject, body mechanics, to answer the question. Visualize each of the items in the options to determine which actions could result in injury. Review the principles of body mechanics if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management Question 22 1 / 1 pts A home care nurse visits a client during the winter, who lives in a small apartment, to perform a dressing change . During the lengthy procedure, the client asks the nurse whether it is safe to use a space heater. What is the appropriate response by the nurse? “A space heater should never be used in an apartment.” “A space heater can be used as long as it is kept at a low setting at all times.” “A space heater can be used as long as it is kept in the bedroom at night in case a fire occurs.” 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “A space heater can be used as long as it’s placed at least 3 feet from anything that may ignite.” Correct! Rationale: Space heaters must be used appropriately because of the risk of fire. A space heater should be placed at least 3 feet from anything that may ignite. A space heater may be used in an apartment if there is ample space and safety precautions are followed. A low setting does not reduce the risk of fire. Placing a heater in a bedroom does not guarantee that it will be 3 feet from anything that may ignite. Test-Taking Strategy: Use the process of elimination, keeping in mind the subject, fire safety. Eliminate the options that include the closed-ended words “never” and “all.” To select from the remaining options, note that the correct option is the only one that specifically defines a safety measure involving the use of a space heater. Review fire safety measures in the home if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Ques 1 / 1 pts tion 23 A nurse is preparing to initiate a continuous tube feeding, using a tube-feeding pump. On bringing the pump to the bedside and preparing to plug in the pump, the nurse discovers that there is no available plug in the wall socket. What should the nurse do? Plug in the pump cord into an available plug above the sink. Ask the health care provider to change the prescription to intermittent feedings. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Determine the need for the appliances now plugged into the needed wall socket. Correct! Use a regular extension cord to allow the use of more than one electrical appliance. Rationale: It is most appropriate for the nurse to assess the situation and determine the need for the appliances already plugged into the needed wall socket. The use of electrical appliances near a sink presents a hazard. It is not appropriate (and is premature) to ask the health care provider to change the prescription, because the prescription is based on the client’s needs. A regular extension cord should not be used because it poses a risk of fire. Test-Taking Strategy: Use process of elimination and the steps of the nursing process to answer the question. The only option that addresses collecting data is the one that involves determining the need for the appliances currently plugged into the needed wall socket. Review electrical safety procedures if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Question 24 1 / 1 pts View video. A nurse, preparing a sterile field on which to perform a dressing change, places the sterile drape on the overbed table. Which actions on the part of the nurse indicate correct understanding of the principles of aseptic technique? Select all that apply. Holding the pair of sterile forceps below waist level area 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Correct! Positioning the sterile field so that it remains in full view Reaching across the sterile field to pick up a sterile gauze Leaving the room to obtain a bottle of sterile normal saline solution Picking up a pair of sterile scissors from the sterile field with a sterile gloved hand Correct! Pouring sterile wound cleansing solution into a sterile cup before donning sterile gloves Correct! Rationale: View video. The principles of surgical asepsis must be followed in the preparation of a sterile field. Among these principles are the following: a sterile object remains sterile only when touched by other sterile objects; only sterile objects may be placed on a sterile field; a sterile object or field out of the range of vision or an object held below the nurse’s waist is to be considered contaminated; a sterile object or field becomes contaminated with prolonged exposure to air; when a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by way of capillary action; fluid flows in the direction of gravity; and a 1-inch edge of a sterile field or container is to be considered contaminated. Test-Taking Strategy: Focus on the subject, use of the principles of aseptic technique. Reading each option carefully and recalling the principles of aseptic technique will direct you to the correct options. Review aseptic technique and the procedure for preparing a sterile field if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 25 1 / 1 pts A licensed practical nurse (LPN) tells the registered nurse (RN) that she administered acetaminophen (Tylenol) to a client by way of the rectal route rather than the prescribed oral route because the client was extremely nauseated. The RN most appropriately takes which action? Correct! Asks the LPN to complete and file an incident report Asks the LPN to check the client in 30 minutes to see whether the nausea has subsided Tells the LPN that she made a sound judgment in administering the medication by way of the rectal route Instructs the LPN to write “pr” (per rectum) on the medication record next to the time at which the medication was administered 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: If a medication is prescribed to be administered by way of the oral route, the nurse may not use an alternate route to administer the medication unless the change is prescribed by the health care provider. The nurse would ask the LPN to complete and file an incident report because the LPN, legally speaking, made a medication error. Telling the LPN that she made a sound judgment in administering the medication by way of the rectal route is incorrect. Although the client must be reassessed and the LPN would document administration of the medication by way of the rectal route in the client’s record, the most appropriate option given is having the LPN complete and file an incident report. Test-Taking Strategy: Use the process of elimination, and note the strategic words “most appropriately.” Focusing on the data in the question indicates that the LPN made a medication error. This will direct you to the correct option. Review the appropriate actions in the event of a medication error if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Ethical/Legal Question 26 1 / 1 pts A nurse receives a telephone call from the admissions office and is told that a client scheduled for an internal radiation implant will be admitted to the nursing unit. Which precaution does the nurse include in the client’s plan of care? Correct! Wearing gloves when emptying the client’s bedpan Allowing the client to ambulate in the hall only once a day Placing the client in a semiprivate room at the end of a hallway 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Placing used linen in double bags and sending a bag to the laundry room every evening Rationale: A primary goal of care for the client with an internal radiation implant is to prevent exposure of others to radiation. Therefore, a client with an internal radiation implant is required to remain in a private room to prevent accidental exposure of other clients, staff, and visitors to radiation. For this reason, a private room with a private bath is essential. All client linens should be kept in the client’s room until the implant is removed. Wearing gloves when emptying the client’s bedpan is the only appropriate intervention, of those provided, for a client with an internal radiation implant. Test-Taking Strategy: Use the process of elimination. Eliminate the option that includes the closed-ended word “only.” Also eliminate the option involving the use of a semiprivate room. To select from the remaining options, use your knowledge of standard precautions and precautions for a client with an internal radiation implant. This will direct you to the correct option. Review radiation safety principles if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Safety Ques 1 / 1 pts tion 27 A nursing instructor is observing a nursing student who is practicing the use of standard precautions in the nursing laboratory. Which observation by the instructor indicates a need for further teaching? The nursing student changes gloves between tasks and procedures. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) The nursing student washes hands before making contact with the client. The nursing student wears a gown to change the bed of an incontinent client. The nursing student washes her hands before glove removal after emptying a Foley bag. Correct! Rationale: Standard precautions require that gloves be removed promptly after use and before the wearer touches noncontaminated surfaces or other clients. Gloves are not washed before removal because splashing of contaminated material may result. Changing gloves between tasks and procedures, washing the hands before making contact with the client, and wearing a gown to change the bed of an incontinent client reflect correct understanding of the principles of standard precautions. Test-Taking Strategy: Note the strategic words “need for further teaching.” These words indicate a negative event query and the need to select the incorrect action. Use the process of elimination, visualizing each of the procedures described in the options. Thinking about the principles of standard precautions will direct you to the correct option. Review the principles associated with standard precautions if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Infection Control Question 28 0.67 / 1 pts A health care provider writes a prescription for the application of a heating pad to a client’s back. Which actions should the nurse take when implementing this prescription? Select all that apply. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Placing the heating pad under the client Adjusting the heating pad to the high setting Correct! Frequently monitoring the client’s skin for signs of burns Reviewing the client’s medical history and risk factors for burns Correct! Examining the heating pad periodically for proper electrical function Correct Answer Question 29 1 / 1 pts A home care nurse is instructing a client in the use of ice packs to treat an eye injury. The nurse instructs the client to take which action? Place the ice pack directly on the eye. Avoid the use of commercially prepared ice bags. Keep the ice pack on the eye continuously for 24 hours. Wrap a plastic bag filled with ice in a pillowcase and place it on the eye. Correct! 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: An ice pack placed directly against the skin or left in place for an extended period carries a risk of tissue damage similar to that of a hot water bottle. To help prevent tissue damage resulting from excessive cold exposure, the ice pack should be removed in most cases after 30 minutes; after a short time it may be reapplied. An ice pack should never be placed directly against the skin; instead, it should be covered with a pillowcase or towel. Commercially prepared ice bags are appropriate for use as ice packs. Test-Taking Strategy: Use knowledge of the subject, safety measures for the use of ice packs, to assist you with the process of elimination to answer the question. Eliminate the options that include the words “directly” and “continuously.” From the remaining options, recall that the use of commercially prepared ice bags for the purpose described in the question is acceptable. Review safety measures for the use of ice packs if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Question 30 1 / 1 pts A fever develops in a client who has been hospitalized for 2 months and is receiving parenteral nutrition by way of a central venous line, and central venous line–related sepsis is diagnosed. The nurse interprets this finding as meaning that this is which type of infection? An iatrogenic infection A result of bacterial colonization A community-acquired infection 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Correct! A health care–associated infection Rationale: Infections that occur during hospitalization, or are a result of hospitalization, are referred to as health care–associated infections, hospital-acquired infections, or nosocomial infections. Colonization is defined as a condition in which microorganisms are present in body tissues; there is no damage to the tissues, and no local signs or symptoms of infection are evident. Iatrogenic infections are infections that involve the client’s normal flora. A community-acquired infection is an infection that the person is admitted with or is incubating on admission to the hospital. Test-Taking Strategy: Focus on the data in the question. Noting that the fever and sepsis developed while the client was hospitalized will direct you to the correct option. Review the various types of infection and the definition of colonization if you had difficulty answering this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Assessment Content Area: Infection Control Question 31 1 / 1 pts A nurse educator is providing inservice sessions to the nursing staff regarding employee safety and the prevention of occupationally acquired HIV infection. Which precautions does the nurse instruct the nursing staff to take as a means of preventing accidental needlesticks? Select all that apply. The use of latex gloves Correct! The use of shielded needles Correct! The use of recessed needles 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Correct! The use of needleless devices Correct! Disposal of needles in special puncture-resistant containers Rationale: Although strict adherence to universal or standard precautions can reduce significantly the incidence of exposure to blood or body fluid, latex gloves cannot prevent a needlestick. The use of recessed needles, needleless devices, shielded needles, and puncture-resistant containers for the disposal of needles are all of significant benefit in the prevention of accidental needlesticks. Test-Taking Strategy: Focus on the subject, preventing accidental needlesticks, to answer the question. Visualize each of the options and how the action might or might not prevent a needlestick. This will help you answer correctly. Review standard precautions if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Infection Control Question 32 1 / 1 pts A nurse is preparing to clean up a blood spill on the client’s bedside table that occurred when a blood tube containing a specimen from the client broke. What steps should the nurse take to clean up the blood spill? Select all that apply. Correct! Using tongs to collect any broken glass Correct! Wearing gloves for the cleanup procedure Placing the pieces of broken glass in a plastic bag 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Blotting up the spill with a face cloth or cloth towel Disinfecting the area of the blood spill with a dilute bleach solution Correct! Rationale: The nurse should blot the spill with an absorbent disposable material such as disposable paper towels or terry wipes, not a face cloth or towel. Tongs are used to pick up any broken glass, and gloves are worn for the procedure. The broken glass is disposed of in a puncture-resistant container. The area is disinfected with a dilute bleach solution or other agency-accepted product. Test-Taking Strategy: Read each option carefully. Use knowledge of the subject, cleaning up a blood spill, to assist you with this question. Visualizing the actions identified in each option and recalling the principles associated with standard precautions will direct you to the correct options. Review the procedure for cleaning up blood spills if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Ques 1 / 1 pts tion 33 The emergency department nurse who is on duty is informed by the charge nurse that an airplane crash has occurred and numerous casualties will be arriving at the ED. What should the initial response by the nurse be? Correct! “Has the disaster plan been activated?” “Call as many nursing staff as you can to come in to work.” “Make sure all of the rooms are well stocked with supplies.” 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) “Be sure that the nursing staff finds as many stretchers as they can.” Rationale: In an external disaster, many people will be brought to the ED for treatment. Although ensuring that rooms are well stocked with supplies, calling nursing staff to come to work, and finding stretchers are components of preparing for the casualties, the initial nursing action must be activation of the disaster plan. Therefore the initial response by the nurse should be “Has the disaster plan been activated?” Test-Taking Strategy: Note the strategic words “initial response” in the query. Focus on the data in the question and note that the correct option is the umbrella response. Review procedures related to management of a disaster if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Disasters Ques 1 / 1 pts tion 34 A community health nurse is providing an educational session on childhood poisoning at a local school. The nurse tells the group that when an accidental poisoning occurs the first action is to take which action? Induce vomiting. Call an ambulance. Correct! Call the poison control center. Bring the child to the emergency department (ED). 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: When a poisoning occurs, a poison control center should be contacted immediately and any directions given regarding treatment followed. The poison control center will provide directions regarding the inducement of vomiting. However, vomiting should not be induced if the victim is unconscious or if the substance ingested is a strong corrosive or petroleum product. The poison control center may advise the mother to bring the child to the ED; if this is the case, the mother should call an ambulance. Neither bringing the child to the ED nor calling an ambulance would be the immediate actions because either tactic would delay treatment. Test-Taking Strategy: Note the strategic word “first” in the query of the question. Eliminate the comparable or alike options that involve a delay in starting treatment (calling an ambulance and bringing the victim to the emergency department). Recalling that vomiting should not be induced in certain types of poisoning will help you eliminate this option. Review immediate poison control measures if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Ques 1 / 1 pts tion 35 A client undergoing chemotherapy is found to have an extremely low white blood cell count, and neutropenic precautions, including a low-bacteria diet, are immediately instituted. Which of these food items will the client be allowed to consume? Select all that apply. Fresh apple Raw celery Correct! Italian bread 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Tossed salad Correct! Baked chicken Correct! Well-cooked cheeseburger Rationale: An extremely low white blood cell count puts the client at risk for infection, necessitating the implementation of a low-bacteria diet. The client must avoid fresh fruits and vegetables, which may harbor microorganisms that could cause infection, and ensure that meat is thoroughly cooked. Italian bread, baked chicken, and a well-done cheeseburger are all acceptable foods for the client. Test-Taking Strategy: Focus on the subject of the question, a low-bacteria diet. Read each option carefully and think about the foods that harbor bacteria. Recalling that fresh fruits and vegetables are restricted in a lowbacteria diet will help you select the correct items. Review interventions for the client on a low-bacteria diet if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control Question 36 1 / 1 pts Which actions should the nurse take in the event of an accidental poisoning? Select all that apply. Correct! Saving vomitus for laboratory analysis Placing the client in the supine position Correct! Determining the type and amount of substance ingested 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Correct! Removing any visible materials from the nose and mouth Inducing vomiting if a household cleaner has been ingested Assessing the client s airway patency, breathing, and circulation Correct! Rationale: In the event of accidental poisoning, the poison center is called before any attempt at interventions is made. Additional interventions in an accidental poisoning include assessing the client’s airway patency, breathing, and circulation; removing any visible materials from the nose and mouth to terminate exposure; determining the type and amount of substance ingested, if possible, to identify an antidote; saving vomitus for laboratory analysis, which may aid further treatment; and positioning the victim with the head to the side to prevent aspiration of vomitus and help keep the airway open. Because of the risk of aspiration, vomiting is never induced in an unconscious client or in a client who is experiencing seizures. Additionally, vomiting is not induced if lye, a household cleaner, a hair-care product, grease, a petroleum product, or furniture polish has been ingested because of the risk of internal burns. Test-Taking Strategy: Focus on the subject, interventions in the event of accidental poisoning. Visualize each of the interventions and how they might be helpful in treating the poisoning. Use of the ABCs (airway, breathing, and circulation) will also help you determine the correct interventions. Remember, too, that caustic substances may cause further injury to the client if vomiting is induced. If you had difficulty with this question, review the interventions for a victim of accidental poisoning. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Ques 1 / 1 pts tion 37 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) A nurse is assigned to care for a client with an infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator that requires frequent suctioning. While gathering the needed supplies before entering the client’s room, which necessary protective items does the nurse obtain? Select all that apply.f Mask Correct! Gown Correct! Gloves Correct! Face shield Shoe protectors Rationale: Infection caused by MRSA necessitates contact precautions. The care of this client requires the use of gown, gloves, and a face shield. The face shield is worn to protect the face and the mucous membranes of the mouth, nose, and eyes during interventions that could produce splashes of blood, body fluids, secretions, and excretions (e.g., wound irrigation and suctioning). Contact precautions also require the use of gloves and a gown if direct client contact is anticipated. A mask does not provide adequate protection. Shoe protectors are not necessary. Test-Taking Strategy: Focus on the data in the question, and think about the events that might occur during a wound irrigation and suctioning. This will help you determine the necessary items for the care of this client. If you had difficulty with this question, review standard and contact precautions. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 38 1 / 1 pts A nurse is assisting with disaster relief after a tornado. The nurse’s goal with the overall community is to prevent as much injury and death resulting from the uncontrollable event as possible. Finding safe housing for survivors, providing support to families, organizing counseling sessions, and securing physical care when needed are all examples of which level of prevention? Initial Primary Correct! Tertiary Secondary Rationale: Tertiary prevention involves the reduction of the amount and degree of disability, injury, and damage after a crisis. Primary prevention is aimed at keeping a crisis from ever occurring, and secondary prevention is focused on reducing the intensity and duration of the crisis during the actual crisis. There is no such thing as the initial prevention level. Test-Taking Strategy: Focus on the data in the question and the nurse’s goal. Note that the goals of care involve activities undertaken after the disaster. This will assist you in identifying the correct level of prevention. If you had difficulty with this question, review the levels of prevention. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Disasters Question 39 1 / 1 pts 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) A nurse in a postanesthesia care unit (PACU) receives a client from the operating room. For what finding should the PACU nurse assess the client first? Correct! Airway patency Active bowel sounds Adequate urine output Orientation to surroundings Rationale: After a client’s transfer from the operating room, the PACU nurse performs an assessment, assessing airway patency first. The client may not have active bowel sounds at this time as a result of the effects of anesthesia. Urine output and orientation to surroundings may also be assessed, but these are not the first priorities. Test-Taking Strategy: Note the strategic word “first.” Use your knowledge of the ABCs—airway, breathing, and circulation—to identify the correct option. Review the initial actions to be taken in the care of a postoperative client if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Question 40 1 / 1 pts A staff nurse caring for a client with a head injury notes that the client is restless and pulling at the intravenous (IV) line. The client’s health care provider does not want to prescribe sedation, and the family has requested that the client not be restrained. Which action by the nurse is appropriate? 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Asking a family member to sit with the client Asking a nursing assistant to monitor the client Staying with the client and consulting with the nurse manager about the situation Correct! Telling the family that the application of wrist restraints is critical in preventing injury to the client Rationale: The nurse must stay with the client and consult with the nurse manager about the situation. It may be necessary for the nurse manager to call the supervisor to request an additional staff member to care for the client. Because the client has a head injury, the development of increased intracranial pressure (ICP) is a major concern. A nursing assistant is not trained to monitor the client for increased ICP. It is inappropriate to ask a family member to sit with the client. The application of restraints may agitate the client, causing further restlessness and thus increasing ICP. Test-Taking Strategy: Use the process of elimination, noting the strategic word “appropriate.” Focus on the data in the question, noting that the client has sustained a head injury, and remember that the client with a head injury is at risk for increased ICP. Eliminate the comparable or alike options (i.e., asking a family member or the nursing assistant to stay with the client). To select from the remaining options, recall that the application of restraints could agitate the client. Review the guidelines for the use of restraints and nursing responsibilities when a client requires continuous monitoring if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Are