Fundamentals HESI Exam Questions & Answers with Rationales Graded A 2023

The nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate from the bed to a chair for the first time following abdominal surgery. What action(s) should the nurse implement prior to assisting the client to the chair? (Select all that apply.) A) Pre-medicate the client with an analgesic B) Inform the client of the plan for moving to the chair C) Obtain and place a portable commode by the bed. D) Ask the client to push the IV pole to the chair. E) Clamp the indwelling catheter. F) Assess the client's blood pressure. - A,B,D,F Pre-medicating the client with an analgesic (A) reduces the client's pain during mobilization and maximizes compliance. To ensure the client's cooperation and promote independence, the nurse should inform the client about the plan for moving to the chair (B) and encourage the client to participate by pushing the IV pole when walking to the chair (D). The nurse should assess the client's blood pressure (F) prior to mobilization, which can cause orthostatic hypotension. (C and E) are not indicated. A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first? A) Hydrogel. B) Exudate absorber. C) Wet to moist dressing. D) Transparent adhesive film - C To provide moisture and loosen the necrotic tissue, the eschar should be covered first with wet to moist dressings (C), which are discontinued and then a hydrogel alginate can be placed in the prepared wound bed to prevent further damage of granulating any surrounding tissue. Although a hydrogel (A) liquefies necrotic tissue of slough and rehydrates the wound bed, it does not address wicking the purulent drainage from the wound. Exudate absorbers (B) provide a moist wound surface, absorb exudate, and support debridement, but do not prepare the woundbed for proper healing. Transparent dressings (D) are used to protect against contamination and friction while maintaining a clean moist surface. The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves? A) Empty the client's urinary drainage bag. B) Draw up the irrigating solution into the syringe. C) Secure the client's catheter to the drainage tubing. D) Use aseptic technique to instill the irrigating solution. - B To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the irrigating solution into the syringe (B). The syringe is then attached to the catheter and the fluid instilled, using aseptic technique (D). Once the irrigating solution is instilled, the client's catheter should be secured to the drainage tubing (C). The urinary drainage bag can be emptied (A) whenever intake and output measurement is indicated, and the instilled irrigating fluid can be subtracted from the output at that time. While caring for a child and mother from Cambodia, what action should the nurse implement to accommodate the clients' cultural needs? A) Speak initially with the oldest family member to show respect. B) Realize that Southeast Asians may not take Western medications. C) Ask the husband to step out during the mother's pelvic examination. D) Tell the family that planning health care is provided in private with the client. - A Members of the Asian culture have high respect for others, especially those in positions of authority. Extended family members need to be included in the nursing care plan (A). Southeast Asians do not necessarily refuse Western medications (B). Asians also believe that touching strangers is not acceptable, particularly health professionals whom they have not previously known, so the husband should be allowed to remain with his wife during the pelvic exam (C). Provided that the presence of other family members is not harmful to the client's well-being, (D) is not correct. The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch in diameter and finds that there is straw-colored drainage seeping fromthe wound. What description of this finding should the nurse include in the client's record? A) Stage 1 pressure sore draining sero-sanguineous drainage. B) Pressure sore at bony prominence with exudate noted. C) One-inch pressure sore draining serous fluid. D) Pressure sore on heel with a small amount of purulent drainage. - C Serous drainage is clear watery plasma, so (C) provides accurate documentation based on the information provided. Information to stage this pressure score (A) is not provided, and sero-sanguineous drainage is pale and watery with a combination of plasma and red cells, and may be blood-streaked. Exudate (B) is fluid such as pus and serum. Purulent drainage (D) is thick, yellow, green, or brown indicating the presence of dead or living organisms and white blood cells. The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. What action is most important for the new staff nurse to take? A) Review the steps in the procedure manual. B) Ask another nurse to assist while implementing the procedure. C) Follow the agency's policy and procedure. D) Refuse to perform the task that is beyond the nurse's experience. - D According to states' nurse practice acts, it is the responsibility of the nurse to function within the scope of competency (D), and in this case safe nursing practice constitutes refusal to perform the procedure because of a lack of experience. Although state mandates, agency policies, and continued education and experience identify tasks that are within the scope of nursing practice, nurses should first refuse to perform tasks that are beyond their proficiency, and then pursue opportunities to enhance their competency (A, B, and C).