HESI - Fundamentals
When turning an immobile bedridden client without assistance,
which action by 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.
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 the skin
or joint. Options C and D are useful techniques while turning a client
but have less priority in 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
B
Rationale: 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.
Brainpower
Read More
Previous
Play
Next
Rewind 10 seconds
Move forward 10 seconds
Unmute
0:00
/
0:15
Full screen
The nurse is aware that malnutrition is a common problem among
clients served by a community health 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
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 clinical
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
nurse 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 the surgery.
D. Reassure the client that the surgeon will answer any questions
before the anesthesia is administered.
C
Rationale: The surgeon should be informed immediately that the
permit is not signed. It is the surgeon's responsibility to explain the
procedure to the client and obtain the client's signature on the
permit. Although the nurse can witness an operative permit, the
procedure must first be explained by the 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 greatest 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
B
Rationale:
Anticoagulants increase the risk for bleeding during surgery, which
can pose a threat for the development of surgical complications.
The health care provider should be informed that the client is taking
these drugs. Although clients who take birth control pills may be
more susceptible to the development 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 client to the chair.
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 never be lifted
under the axillae; this could damage nerves and strain the nurse's
back. The client should be instructed to use the arms of the chair
When turning an immobile bedridden client without assistance,
which action by 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.
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 the skin
or joint. Options C and D are useful techniques while turning a client
but have less priority in 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
B
Rationale: 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.
Brainpower
Read More
Previous
Play
Next
Rewind 10 seconds
Move forward 10 seconds
Unmute
0:00
/
0:15
Full screen
The nurse is aware that malnutrition is a common problem among
clients served by a community health 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
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 clinical
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
nurse 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 the surgery.
D. Reassure the client that the surgeon will answer any questions
before the anesthesia is administered.
C
Rationale: The surgeon should be informed immediately that the
permit is not signed. It is the surgeon's responsibility to explain the
procedure to the client and obtain the client's signature on the
permit. Although the nurse can witness an operative permit, the
procedure must first be explained by the 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 greatest 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
B
Rationale:
Anticoagulants increase the risk for bleeding during surgery, which
can pose a threat for the development of surgical complications.
The health care provider should be informed that the client is taking
these drugs. Although clients who take birth control pills may be
more susceptible to the development 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 client to the chair.
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 never be lifted
under the axillae; this could damage nerves and strain the nurse's
back. The client should be instructed to use the arms of the chair
