HESI RN FUNDAMENTALS EXAM ( BUNDLES )

HESI RN FUNDAMENTALS EXAM e e e




When turning an immobile bedridden client without assistance, which action bythe n
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urse best ensures client safety?
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A.
Securely grasp the client's arm and leg.e e e e e e e


B.
Put bed rails up on the side of bed opposite from the nurse.C.
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Correctly position and use a turn sheet. e e e e e e e


D.
Lower the head of the client's bed slowly.(
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ANS- B. e


Rationale :Because the nurse can only stand on one side of the bed, bed rails should b
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e up on the opposite side to ensure that the client does not fall out of bed.Option A can
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cause client injury to the skin or joint. Options C and D are useful techniques while t
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urning a client but have less priority in terms of safety than useof the bed r
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The nurse identifies a potential for infection in a client with partial-
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thickness(second-degree) and full-thickness (third-
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degree) burns. What action has thehighest priority in decreasing the client's ris
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k of infection?
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A.
Administration of plasma expanders e e e e


B.
Use of careful hand washing technique
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C.
Application of a topical antibacterial cream e e e e e e


D.
Limiting visitors to the client with burns(
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ANS- B e


Careful hand washing technique is the single most effective intervention for the preve
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ntion of contamination to all clients. Option A reverses the hypovolemia that initially
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accompanies burn trauma but is not related to decreasing the proliferation of infective
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organisms. Options C and D are recommended by various burn centers
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,as possible ways to reduce the chance of infection. Option B is a proven techniqueto p
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revent infection e




The nurse is aware that malnutrition is a common problem among clients served bya c
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ommunity health clinic for the homeless. Which laboratory value is the most reliable i
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ndicator of chronic protein malnutrition? e e e e


A.
Low serum albumin level e e e e


B.
Low serum transferrin level
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C.
High hemoglobin level e e e


D.
High cholesterol level e e e


(ANS- A e


Rationale:
Long-
term protein deficiency is required to cause significantly lowered serum albumin lev
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els. Albumin is made by the liver only when adequate amounts of amino acids (from
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protein breakdown) are available. Albumin has a long half-
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life,so acute protein loss does not significantly alter serum levels. Option B is a seru
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mprotein with a half-
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life of only 8 to 10 days, so it will drop with an acute protein deficiency. Options C an
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d D are not clinical measures of protein malnutrition.
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In completing a client's preoperative routine, the nurse finds that the operative permi
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t is not signed. The client begins to ask more questions about the surgicalprocedure.
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Which action should the nurse take next?e e e e e e




A.
Witness the client's signature to the permit.B e e e e e e e


.
Answer the client's questions about the surgery.C.
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Inform the surgeon the client has questions about the surgery.D.
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,Reassure the client that the surgeon will answer any questions before theanesthesia is
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eadministered.
(ANS- C e


Rationale:
It is the surgeon's responsibility to explain the procedure to the client and obtain the c
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lient's signature on the permit. Although the nurse can witness an operative permit, t
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he procedure must first be explained by the health care provider or surgeon, includin
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g answering the client's questions. The client's questions shouldbe addressed before t
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he permit is signed.
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The nurse is assessing several clients prior to surgery. Which factor in a client'shistory
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poses the greatest threat for complications to occur during surgery?
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A.
Taking birth control pills for the past 2 yearsB.
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Taking anticoagulants for the past year
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C.
Recently completing antibiotic therapy e e e e


D.
Having taken laxatives PRN for the last 6 months(
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ANS- B e


Rationale:
Anticoagulants increase the risk for bleeding during surgery, which can pose a threat
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for the development of surgical complications. The health care provider should be in
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formed that the client is taking these drugs. Although clients who takebirth control pi
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lls may be more susceptible to the development of thrombi, such problems usually oc
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cur postoperatively. A client with option C or D is at less of a surgical risk than with o
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ption B. e




When assisting a client from the bed to a chair, which procedure is best for thenurse t
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o follow?
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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 theaxillae.
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D.
Stand beside the client, place the client's arms around the nurse's neck, and gentlymove
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the client to the chair.
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(ANS- B e


Rationale:
Option B describes the correct positioning of the nurse and affords the nurse a wide b
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ase of support while stabilizing the client's knees when assisting to a standing positio
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n. The chair should be placed at a 45-
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degree angle to the bed, withthe back of the chair toward the head of the bed. Clients s
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hould never be lifted under the axillae; this could damage nerves and strain the nurse'
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s back. The client should be instructed to use the arms of the chair and should never pl
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ace his or her arms around the nurse's neck; this places undue stress on the nurse's nec
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k and backand increases the risk for a fall.
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Which steps should the nurse take when administering ear drops to an adult client?(Sel
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ect all that apply.)
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A.
Place the client in a side- e e e e e


lying position.B. e e


Pull the auricle upward and outward.
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C.
Hold the dropper 6 cm above the ear canal.D
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.
Place a cotton ball into the inner canal.E
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.
Pull the auricle down and back.
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