HESI RN FUNDAMENTALS q q
1. When turning an immobile bedridden client without assistance, which action b
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y the nurse best ensures client safety?
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q
A. Securely grasp the client's arm and leg.
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q
B. Put bed rails up on the side of bed opposite from the nurse.
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q
C. Correctly position and use a turn sheet.
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q
D. Lower the head of the client's bed slowly.
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Rationale:
Because the nurse can only stand on one side of the bed, bed rails should be up on the
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opposite side to ensure that the client does not fall out of bed. Option A can cause clie
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nt injury to the skin or joint. Options C and D are useful techniques while turning a cli
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ent but have less priority in terms of safety than use of the bed rails.
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2. The nurse identifies a potential for infection in a client with partial-
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thickness (second-degree) and full-thickness (third- q q q q
degree) burns. What intervention has the highest priority in decreasing the clie
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nt's risk of infection?
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q
A. Administration of plasma expanders
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q
B. Use of careful handwashing technique
q q q q q
q
C. Application of a topical antibacterial cream
q q q q q q
q
D. Limiting visitors to the client with burns
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Rationale:
Careful handwashing technique is the single most effective intervention for the preve
q q q q q q q q q q q
ntion of contamination to all clients. Option A reverses the hypovolemia that initially
q q q q q q q q q q q q q
accompanies burn trauma but is not related to decreasing the proliferation of infectiv
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e organisms. Options C and D are recommended by various burn centers as possible
q q q q q q q q q q q q q q
ways to reduce the chance of infection. Option B is a proven technique to prevent infe
q q q q q q q q q q q q q q q
ction.
, 3. The nurse is aware that malnutrition is a common problem among clients serve
q q q q q q q q q q q q
d by a community health clinic for the homeless. Which laboratory value is the
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most reliable indicator of chronic protein malnutrition?
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q
A. Low serum albumin level
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q
B. Low serum transferrin level
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q
C. High hemoglobin level
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q
D. High cholesterol level
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Rationale:
Long-
term protein deficiency is required to cause significantly lowered serum albumin leve
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ls. Albumin is made by the liver only when adequate amounts of amino acids (from pr
q q q q q q q q q q q q q q q
otein 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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m protein 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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4. In completing a client's preoperative routine, the nurse finds that the operative
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permit is not signed. The client begins to ask more questions about the surgical
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procedure. Which action should the nurse take next? q q q q q q q
q
A Witness the client's signature to the permit.
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.
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B Answer the client's questions about the surgery.
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.
q
C Inform the surgeon that the operative permit is not signed and the client has quest
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. ions about the surgery. q q q
q
D Reassure the client that the surgeon will answer any questions before the anesthe
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. sia is administered. q q
Rationale:
The surgeon should be informed immediately that the permit is not signed. It is the su
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rgeon's responsibility to explain the procedure to the client and obtain the client's sign
q q q q q q q q q q q q q
ature on the permit. Although the nurse can witness an operative permit, the procedur
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e must first be explained by the health care provider or surgeon, including answering
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the client's questions. The client's questions should be addressed before the permit is
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signed.
, 5. The nurse is assessing several clients prior to surgery. Which factor in a client's
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history poses the greatest threat for complications to occur during surgery?
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q
A. Taking birth control pills for the past 2 years
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q
B. Taking anticoagulants for the past year
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q
C. Recently completing antibiotic therapy
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q
D. Having taken laxatives PRN for the last 6 months
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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 inf
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ormed that the client is taking these drugs. Although clients who take birth control pil
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ls may be more susceptible to the development of thrombi, such problems usually occ
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ur postoperatively. A client with option C or D is at less of a surgical risk than with op
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tion B. q
6. When assisting a client from the bed to a chair, which procedure is best for the
q q q q q q q q q q q q q q q q
nurse to follow? q q
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A Place the chair parallel to the bed, with its back toward the head of the bed and ass
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. ist the client in moving to the chair.
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q q
B With the nurse's feet spread apart and knees aligned with the client's knees, stand
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. and pivot the client into the chair.
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q q
C Assist the client to a standing position by gently lifting upward, underneath the ax
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. illae.
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D Stand beside the client, place the client's arms around the nurse's neck, and gently
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. move the client to the chair.
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Rationale:
Option B describes the correct positioning of the nurse and affords the nurse a wide b
q q q q q q q q q q q q q q q
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-
q q q q q q q q
degree angle to the bed, with the back of the chair toward the head of the bed. Clients
q q q q q q q q q q q q q q q q q q
should never be lifted under the axillae; this could damage nerves and strain the nurse
q q q q q q q q q q q q q q
's back. The client should be instructed to use the arms of the chair and should never p
q q q q q q q q q q q q q q q q q
, lace his or her arms around the nurse's neck; this places undue stress on the nurse's ne
q q q q q q q q q q q q q q q q
ck and back and increases the risk for a fall.
q q q q q q q q q
7.Which step(s) should the nurse take when administering ear drops to an adult cli
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ent? (Select all that apply.)
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q
A. Place the client in a side-lying position.
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q
B. Pull the auricle upward and outward.
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q
C. Hold the dropper 6 cm above the ear canal.
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q
D. Place a cotton ball into the inner canal.
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q
E. Pull the auricle down and back.
q q q q q q
Rationale:
The correct answers (A and B) are the appropriate administration of ear drops. The dr
q q q q q q q q q q q q q q
opper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be pl
q q q q q q q q q q q q q q q q q q
aced in the outermost canal (D). The auricle is pulled down and back for a child youn
q q q q q q q q q q q q q q q q
ger than 3 years of age, but not an adult (E).
q q q q q q q q q q
8.The nurse is instructing a client in the proper use of a metered-
q q q q q q q q q q q q
dose inhaler. Which instruction should the nurse provide the client to ensure the opti
q q q q q q q q q q q q q
mal benefits from the drug?
q q q q
q
A. "Fill your lungs with air through your mouth and then compress the inhaler."
q q q q q q q q q q q q q
q
B. "Compress the inhaler while slowly breathing in through your mouth."
q q q q q q q q q q
q
C. "Compress the inhaler while inhaling quickly through your nose."
q q q q q q q q q
q
D. "Exhale completely after compressing the inhaler and then inhale."
q q q q q q q q q
Rationale:
The medication should be inhaled through the mouth simultaneously with compressi
q q q q q q q q q q
on of the inhaler. This will facilitate the desired destination of the aerosol medication
q q q q q q q q q q q q q q
deep in the lungs for an optimal bronchodilation effect. Options A, C, and D do not al
q q q q q q q q q q q q q q q q
low for deep lung penetration
q q q q
9. A 20-year-
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old female client with a noticeable body odor has refused to shower for the last 3 days
q q q q q q q q q q q q q q q q
. She states, "I have been told that it is harmful to bathe during my period." Which acti
q q q q q q q q q q q q q q q q q
on should the nurse take first?
q q q q q
1. When turning an immobile bedridden client without assistance, which action b
q q q q q q q q q q
y the nurse best ensures client safety?
q q q q q q
q
A. Securely grasp the client's arm and leg.
q q q q q q q
q
B. Put bed rails up on the side of bed opposite from the nurse.
q q q q q q q q q q q q q
q
C. Correctly position and use a turn sheet.
q q q q q q q
q
D. Lower the head of the client's bed slowly.
q q q q q q q q
Rationale:
Because the nurse can only stand on one side of the bed, bed rails should be up on the
q q q q q q q q q q q q q q q q q q q
opposite side to ensure that the client does not fall out of bed. Option A can cause clie
q q q q q q q q q q q q q q q q q
nt injury to the skin or joint. Options C and D are useful techniques while turning a cli
q q q q q q q q q q q q q q q q q
ent but have less priority in terms of safety than use of the bed rails.
q q q q q q q q q q q q q q
2. The nurse identifies a potential for infection in a client with partial-
q q q q q q q q q q q
thickness (second-degree) and full-thickness (third- q q q q
degree) burns. What intervention has the highest priority in decreasing the clie
q q q q q q q q q q q
nt's risk of infection?
q q q
q
A. Administration of plasma expanders
q q q q
q
B. Use of careful handwashing technique
q q q q q
q
C. Application of a topical antibacterial cream
q q q q q q
q
D. Limiting visitors to the client with burns
q q q q q q q
Rationale:
Careful handwashing technique is the single most effective intervention for the preve
q q q q q q q q q q q
ntion of contamination to all clients. Option A reverses the hypovolemia that initially
q q q q q q q q q q q q q
accompanies burn trauma but is not related to decreasing the proliferation of infectiv
q q q q q q q q q q q q
e organisms. Options C and D are recommended by various burn centers as possible
q q q q q q q q q q q q q q
ways to reduce the chance of infection. Option B is a proven technique to prevent infe
q q q q q q q q q q q q q q q
ction.
, 3. The nurse is aware that malnutrition is a common problem among clients serve
q q q q q q q q q q q q
d by a community health clinic for the homeless. Which laboratory value is the
q q q q q q q q q q q q q q
most reliable indicator of chronic protein malnutrition?
q q q q q q
q
A. Low serum albumin level
q q q q
q
B. Low serum transferrin level
q q q q
q
C. High hemoglobin level
q q q
q
D. High cholesterol level
q q q
Rationale:
Long-
term protein deficiency is required to cause significantly lowered serum albumin leve
q q q q q q q q q q q
ls. Albumin is made by the liver only when adequate amounts of amino acids (from pr
q q q q q q q q q q q q q q q
otein breakdown) are available. Albumin has a long half-
q q q q q q q q
life, so acute protein loss does not significantly alter serum levels. Option B is a seru
q q q q q q q q q q q q q q q
m protein with a half-
q q q q
life of only 8 to 10 days, so it will drop with an acute protein deficiency. Options C an
q q q q q q q q q q q q q q q q q q
d D are not clinical measures of protein malnutrition.
q q q q q q q q
4. In completing a client's preoperative routine, the nurse finds that the operative
q q q q q q q q q q q q
permit is not signed. The client begins to ask more questions about the surgical
q q q q q q q q q q q q q q
procedure. Which action should the nurse take next? q q q q q q q
q
A Witness the client's signature to the permit.
q q q q q q q
.
q
B Answer the client's questions about the surgery.
q q q q q q q
.
q
C Inform the surgeon that the operative permit is not signed and the client has quest
q q q q q q q q q q q q q q q
. ions about the surgery. q q q
q
D Reassure the client that the surgeon will answer any questions before the anesthe
q q q q q q q q q q q q q
. sia is administered. q q
Rationale:
The surgeon should be informed immediately that the permit is not signed. It is the su
q q q q q q q q q q q q q q q
rgeon's responsibility to explain the procedure to the client and obtain the client's sign
q q q q q q q q q q q q q
ature on the permit. Although the nurse can witness an operative permit, the procedur
q q q q q q q q q q q q q
e must first be explained by the health care provider or surgeon, including answering
q q q q q q q q q q q q q q
the client's questions. The client's questions should be addressed before the permit is
q q q q q q q q q q q q q
signed.
, 5. The nurse is assessing several clients prior to surgery. Which factor in a client's
q q q q q q q q q q q q q
history poses the greatest threat for complications to occur during surgery?
q q q q q q q q q q q
q
A. Taking birth control pills for the past 2 years
q q q q q q q q q
q
B. Taking anticoagulants for the past year
q q q q q q
q
C. Recently completing antibiotic therapy
q q q q
q
D. Having taken laxatives PRN for the last 6 months
q q q q q q q q q
Rationale:
Anticoagulants increase the risk for bleeding during surgery, which can pose a threat
q q q q q q q q q q q q q
for the development of surgical complications. The health care provider should be inf
q q q q q q q q q q q q
ormed that the client is taking these drugs. Although clients who take birth control pil
q q q q q q q q q q q q q q
ls may be more susceptible to the development of thrombi, such problems usually occ
q q q q q q q q q q q q q
ur postoperatively. A client with option C or D is at less of a surgical risk than with op
q q q q q q q q q q q q q q q q q q
tion B. q
6. When assisting a client from the bed to a chair, which procedure is best for the
q q q q q q q q q q q q q q q q
nurse to follow? q q
q q
A Place the chair parallel to the bed, with its back toward the head of the bed and ass
q q q q q q q q q q q q q q q q q
. ist the client in moving to the chair.
q q q q q q q
q q
B With the nurse's feet spread apart and knees aligned with the client's knees, stand
q q q q q q q q q q q q q q
. and pivot the client into the chair.
q q q q q q
q q
C Assist the client to a standing position by gently lifting upward, underneath the ax
q q q q q q q q q q q q q
. illae.
q q
D Stand beside the client, place the client's arms around the nurse's neck, and gently
q q q q q q q q q q q q q
. move the client to the chair.
q q q q q q
Rationale:
Option B describes the correct positioning of the nurse and affords the nurse a wide b
q q q q q q q q q q q q q q q
ase of support while stabilizing the client's knees when assisting to a standing positio
q q q q q q q q q q q q q
n. The chair should be placed at a 45-
q q q q q q q q
degree angle to the bed, with the back of the chair toward the head of the bed. Clients
q q q q q q q q q q q q q q q q q q
should never be lifted under the axillae; this could damage nerves and strain the nurse
q q q q q q q q q q q q q q
's back. The client should be instructed to use the arms of the chair and should never p
q q q q q q q q q q q q q q q q q
, lace his or her arms around the nurse's neck; this places undue stress on the nurse's ne
q q q q q q q q q q q q q q q q
ck and back and increases the risk for a fall.
q q q q q q q q q
7.Which step(s) should the nurse take when administering ear drops to an adult cli
q q q q q q q q q q q q q
ent? (Select all that apply.)
q q q q
q
A. Place the client in a side-lying position.
q q q q q q q
q
B. Pull the auricle upward and outward.
q q q q q q
q
C. Hold the dropper 6 cm above the ear canal.
q q q q q q q q q
q
D. Place a cotton ball into the inner canal.
q q q q q q q q
q
E. Pull the auricle down and back.
q q q q q q
Rationale:
The correct answers (A and B) are the appropriate administration of ear drops. The dr
q q q q q q q q q q q q q q
opper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be pl
q q q q q q q q q q q q q q q q q q
aced in the outermost canal (D). The auricle is pulled down and back for a child youn
q q q q q q q q q q q q q q q q
ger than 3 years of age, but not an adult (E).
q q q q q q q q q q
8.The nurse is instructing a client in the proper use of a metered-
q q q q q q q q q q q q
dose inhaler. Which instruction should the nurse provide the client to ensure the opti
q q q q q q q q q q q q q
mal benefits from the drug?
q q q q
q
A. "Fill your lungs with air through your mouth and then compress the inhaler."
q q q q q q q q q q q q q
q
B. "Compress the inhaler while slowly breathing in through your mouth."
q q q q q q q q q q
q
C. "Compress the inhaler while inhaling quickly through your nose."
q q q q q q q q q
q
D. "Exhale completely after compressing the inhaler and then inhale."
q q q q q q q q q
Rationale:
The medication should be inhaled through the mouth simultaneously with compressi
q q q q q q q q q q
on of the inhaler. This will facilitate the desired destination of the aerosol medication
q q q q q q q q q q q q q q
deep in the lungs for an optimal bronchodilation effect. Options A, C, and D do not al
q q q q q q q q q q q q q q q q
low for deep lung penetration
q q q q
9. A 20-year-
q q
old female client with a noticeable body odor has refused to shower for the last 3 days
q q q q q q q q q q q q q q q q
. She states, "I have been told that it is harmful to bathe during my period." Which acti
q q q q q q q q q q q q q q q q q
on should the nurse take first?
q q q q q
