HESI RN FUNDAMENTALS EXAM ( BUNDLES )

HESI RN FUNDAMENTALS EXAM.. e e e




The nurse selects the best site for insertion of an IV catheter in the client's rightarm
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. Which documentation should the nurse use to identify placement of the IVaccess
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?

A.Left brachial vein e e e


B.Right cephalic vein e e


C.Dorsal side of the right wrist e e e e e e


D.Right upper extremity e e


(ANS- B e


Rationale:
The cephalic vein is large and superficial and identifies the anatomic name of the vein
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that is accessed, which should be included in the documentation (B). The basilic vein
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of the arm is used for IV access, not the brachial vein (A), which is toodeep to be acces
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sed for IV infusion. Although veins on the dorsal side of the right wrist (C) are visible,
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they are fragile and using them would be painful, so they are not recommended for IV
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access. (D) is not specific enough for documenting the location of the IV access.
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When assisting a client from the bed to a chair, which procedure is best for thenurse to
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follow?

A.Place the chair parallel to the bed, with its back toward the head of the bed andassist t
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he client in moving to the chair.
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B.With the nurse's feet spread apart and knees aligned with the client's knees, standand
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pivot the client into the chair.
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C.Assist the client to a standing position by gently lifting upward, underneath theaxill
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ae.

,D.Stand beside the client, place the client's arms around the nurse's neck, andge
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ntly move the client to the chair.
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(ANS- B e




Rationale:
(B) describes the correct positioning of the nurse and affords the nurse a wide baseof s
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upport while stabilizing the client's knees when assisting to a standing position.The c
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hair should be placed at a 45-
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degree angle to the bed, with the back of the chair toward the head of the bed (A). Clie
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nts should never be lifted under the axillae (C); this could damage nerves and strain th
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e nurse's back. The client shouldbe instructed to use the arms of the chair and should n
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ever place his or her arms around the nurse's neck (D); this places undue stress on the
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nurse's neck and back and increases the risk for a fall.
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The nurse is preparing an older client for discharge. Which method is best for thenur
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se to use when evaluating the client's ability to perform a dressing change at home?
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A.

Determine how the client feels about changing the dressing.B.
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Ask the client to describe the procedure in writing.C
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.

Seek a family member's evaluation of the client's ability to change the dressing.D.
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Observe the client change the dressing unassisted.(
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ANS- D e




Rationale:
Observing the client directly (D) will allow the nurse to determine if mastery of theskill
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has been obtained and provide an opportunity to affirm the skill. (A) may be
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,therapeutic but will not provide an opportunity to evaluate the client's ability toperform
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the procedure. (B) may be threatening to an older client and will not determine his abili
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ty. (C) is not as effective as direct observation by the nurse.
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A female nurse is assigned to care for a close friend, who says, "I am worried that frien
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ds will find out about my diagnosis." The nurse tells her friend that legally shemust prot
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ect a client's confidentiality. Which resource describes the nurse's legal responsibilitie
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s?

A.

Code of Ethics for Nurses
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B.

State Nurse Practice Acte e e e


C.

Patient's Bill of Rights e e e e


D.

ANA Standards of Practice
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(ANS- B e




Rationale:
The State Nurse Practice Act (B) contains legal requirements for the protection of clien
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t confidentiality and the consequences for breaches in confidentiality. (A) outlines ethi
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cal standards for nursing care but does not include legal guidelines. (Cand D) describe e
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xpectations for nursing practice but do not address legal implications.
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One week after being told that she has terminal cancer with a life expectancy of 3weeks
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, a female client tells the nurse, "I think I will plan a big party for all my friends." How s
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hould the nurse respond? e e e




A.

, "You may not have enough energy before long to hold a big party."B.
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"Do you mean to say that you want to plan your funeral and wake?"C.
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"Planning a party and thinking about all your friends sounds like fun."D.
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"You should be thinking about spending your last days with your family."(A
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NS- C e




Rationale:
Setting goals that bring pleasure are appropriate and should be encouraged by the nurse
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e(C) as long as the nurse does not perpetuate a client's denial. (A) is a negativeresponse,
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implying that the client should not plan a party. (B) puts words in the client's mouth tha
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t may not be accurate. The nurse should support the client's goals rather than telling the
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client how to spend her time (D).
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After a needlestick occurs while removing the cap from a sterile needle, whichaction s
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hould the nurse implement?
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A.

Complete an incident report. e e e e


B.

Select another sterile needle.
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C.

Disinfect the needle with an alcohol swab.D.
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Notify the supervisor of the department immediately.
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