Safety HESI Prep Adult Care: Questions With Solutions
The nurse has just assisted a client back to bed after a fall. The nurse and
health care provider have assessed the client and have determined that the
client is not injured. After completing the incident report, the nurse should
implement which action next?
a) Reassess the client.
b) Conduct a staff meeting to describe the fall.
c) Document in the nurse's notes that an incident report was completed.
d) Contact the nursing supervisor to update information regarding the fall.
Right Ans - a) Reassess the client.
Rationale: After a client's fall, the nurse must frequently reassess the client
because potential complications do not always appear immediately after the
fall. The client's fall should be treated as private information and shared on a
"need to know" basis. Communication regarding the event should involve only
the individuals participating in the client's care. An incident report is a
problem-solving document; however, its completion is not documented in the
nurse's notes. If the nursing supervisor has been made aware of the incident,
the supervisor will contact the nurse if status update is necessary.
A client is being weaned from parenteral nutrition (PN), also known as total
parenteral nutrition, and is expected to begin taking solid food today. The
ongoing solution rate has been 100 mL/hour. The nurse anticipates that
which prescription regarding the PN solution will accompany the diet
prescription?
a) Discontinue the PN.
b) Decrease PN rate to 50 mL/hour.
c) Start 0.9% normal saline at 25 mL/hour.
d) Continue current infusion rate prescriptions for PN. Right Ans - b)
Decrease PN rate to 50 mL/hour.
,Rationale: When a client begins eating a regular diet after a period of receiving
PN, the PN is decreased gradually. PN that is discontinued abruptly can cause
hypoglycemia. Clients often have anorexia after being without food for some
time, and the digestive tract also is not used to producing the digestive
enzymes that will be needed. Gradually decreasing the infusion rate allows the
client to remain adequately nourished during the transition to a normal diet
and prevents the occurrence of hypoglycemia. Even before clients are started
on a solid diet, they are given clear liquids followed by full liquids to further
ease the transition. A solution of normal saline does not provide the glucose
needed during the transition of discontinuing the PN and could cause the
client to experience hypoglycemia.
The nurse is preparing to change the parenteral nutrition (PN) solution bag
and tubing. The client's central venous line is located in the right subclavian
vein. The nurse asks the client to take which essential action during the tubing
change?
a) Breathe normally.
b) Turn the head to the right.
c) Exhale slowly and evenly.
d) Take a deep breath, hold it, and bear down. Right Ans - d) Take a deep
breath, hold it, and bear down.
Rationale: The client should be asked to perform the Valsalva maneuver
during tubing changes. This helps avoid air embolism during tubing changes.
The nurse asks the client to take a deep breath, hold it, and bear down. If the
intravenous line is on the right, the client turns his or her head to the left. This
position increases intrathoracic pressure. Breathing normally and exhaling
slowly and evenly are inappropriate and could enhance the potential for an air
embolism during the tubing change.
The nurse is preparing to hang fat emulsion (lipids) and notes that fat globules
are visible at the top of the solution. The nurse should take which action?
a) Rolls the bottle of solution gently
b) Obtains a different bottle of solution
c) Shakes the bottle of solution vigorously
,d) Runs the bottle of solution under warm water Right Ans - b) Obtains a
different bottle of solution
Rationale: Fat emulsion (lipids) is a white, opaque solution administered
intravenously during parenteral nutrition therapy to prevent fatty acid
deficiency. The nurse should examine the bottle of fat emulsion for separation
of emulsion into layers of fat globules or for the accumulation of froth. The
nurse should not hang a fat emulsion if any of these are observed and should
return the solution to the pharmacy. Therefore the remaining options are
inappropriate actions.
The nurse is preparing to initiate an intravenous line containing a high dose of
potassium chloride and plans to use an intravenous infusion pump. The nurse
brings the pump to the bedside, prepares to plug the pump cord into the wall,
and notes that no receptacle is available in the wall socket. The nurse should
take which action?
a) Initiate the intravenous line without the use of a pump.
b) Contact the electrical maintenance department for assistance.
c) Plug in the pump cord in the available plug above the room sink.
d) Use an extension cord from the nurses' lounge for the pump plug. Right
Ans - b) Contact the electrical maintenance department for assistance.
Rationale: Electrical equipment must be maintained in good working order
and should be grounded; otherwise it presents a physical hazard. An
intravenous line that contains a dose of potassium chloride should be
administered by an infusion pump. The nurse needs to use hospital resources
for assistance. A regular extension cord should not be used because it poses a
risk for fire. Use of electrical appliances near a sink also presents a hazard.
The nurse obtains a prescription from a health care provider to restrain a
client and instructs an unlicensed assistive personnel (UAP) to apply the
safety device to the client. Which observation by the nurse indicates unsafe
application of the safety device by the UAP?
a) Placing a safety knot in the safety device straps
b) Safely securing the safety device straps to the side rails
, c) Applying safety device straps that do not tighten when force is applied
against them
d) Securing so that two fingers can slide easily between the safety device and
the client's skin Right Ans - b) Safely securing the safety device straps to
the side rails
Rationale: The safety device straps are secured to the bed frame and never to
the side rail to avoid accidental injury in the event that the side rail is
released. A half-bow or safety knot should be used for applying a safety device
because it does not tighten when force is applied against it and it allows quick
and easy removal of the safety device in case of an emergency. The safety
device should be secure, and one or two fingers should slide easily between
the safety device and the client's skin.
The nurse is reviewing a plan of care for a client with an internal radiation
implant. Which intervention if noted in the plan indicates the need for
revision of the plan?
a) Wearing gloves when emptying the client's bedpan
b) Keeping all linens in the room until the implant is removed
c) Wearing a lead apron when providing direct care to the client
d) Placing the client in a semiprivate room at the end of the hallway Right
Ans - d) Placing the client in a semiprivate room at the end of the hallway
Rationale: A private room with a private bath is essential if a client has an
internal radiation implant. This is necessary to prevent accidental exposure of
other clients to radiation. The remaining options identify accurate
interventions for a client with an internal radiation implant and protect the
nurse from exposure.
The nurse enters a client's room and finds that the wastebasket is on fire. The
nurse immediately assists the client out of the room. What is the next nursing
action?
a) Call for help.
b) Extinguish the fire.
c) Activate the fire alarm.
d) Confine the fire by closing the room door. Right Ans - d) Confine the fire
by closing the room door.
The nurse has just assisted a client back to bed after a fall. The nurse and
health care provider have assessed the client and have determined that the
client is not injured. After completing the incident report, the nurse should
implement which action next?
a) Reassess the client.
b) Conduct a staff meeting to describe the fall.
c) Document in the nurse's notes that an incident report was completed.
d) Contact the nursing supervisor to update information regarding the fall.
Right Ans - a) Reassess the client.
Rationale: After a client's fall, the nurse must frequently reassess the client
because potential complications do not always appear immediately after the
fall. The client's fall should be treated as private information and shared on a
"need to know" basis. Communication regarding the event should involve only
the individuals participating in the client's care. An incident report is a
problem-solving document; however, its completion is not documented in the
nurse's notes. If the nursing supervisor has been made aware of the incident,
the supervisor will contact the nurse if status update is necessary.
A client is being weaned from parenteral nutrition (PN), also known as total
parenteral nutrition, and is expected to begin taking solid food today. The
ongoing solution rate has been 100 mL/hour. The nurse anticipates that
which prescription regarding the PN solution will accompany the diet
prescription?
a) Discontinue the PN.
b) Decrease PN rate to 50 mL/hour.
c) Start 0.9% normal saline at 25 mL/hour.
d) Continue current infusion rate prescriptions for PN. Right Ans - b)
Decrease PN rate to 50 mL/hour.
,Rationale: When a client begins eating a regular diet after a period of receiving
PN, the PN is decreased gradually. PN that is discontinued abruptly can cause
hypoglycemia. Clients often have anorexia after being without food for some
time, and the digestive tract also is not used to producing the digestive
enzymes that will be needed. Gradually decreasing the infusion rate allows the
client to remain adequately nourished during the transition to a normal diet
and prevents the occurrence of hypoglycemia. Even before clients are started
on a solid diet, they are given clear liquids followed by full liquids to further
ease the transition. A solution of normal saline does not provide the glucose
needed during the transition of discontinuing the PN and could cause the
client to experience hypoglycemia.
The nurse is preparing to change the parenteral nutrition (PN) solution bag
and tubing. The client's central venous line is located in the right subclavian
vein. The nurse asks the client to take which essential action during the tubing
change?
a) Breathe normally.
b) Turn the head to the right.
c) Exhale slowly and evenly.
d) Take a deep breath, hold it, and bear down. Right Ans - d) Take a deep
breath, hold it, and bear down.
Rationale: The client should be asked to perform the Valsalva maneuver
during tubing changes. This helps avoid air embolism during tubing changes.
The nurse asks the client to take a deep breath, hold it, and bear down. If the
intravenous line is on the right, the client turns his or her head to the left. This
position increases intrathoracic pressure. Breathing normally and exhaling
slowly and evenly are inappropriate and could enhance the potential for an air
embolism during the tubing change.
The nurse is preparing to hang fat emulsion (lipids) and notes that fat globules
are visible at the top of the solution. The nurse should take which action?
a) Rolls the bottle of solution gently
b) Obtains a different bottle of solution
c) Shakes the bottle of solution vigorously
,d) Runs the bottle of solution under warm water Right Ans - b) Obtains a
different bottle of solution
Rationale: Fat emulsion (lipids) is a white, opaque solution administered
intravenously during parenteral nutrition therapy to prevent fatty acid
deficiency. The nurse should examine the bottle of fat emulsion for separation
of emulsion into layers of fat globules or for the accumulation of froth. The
nurse should not hang a fat emulsion if any of these are observed and should
return the solution to the pharmacy. Therefore the remaining options are
inappropriate actions.
The nurse is preparing to initiate an intravenous line containing a high dose of
potassium chloride and plans to use an intravenous infusion pump. The nurse
brings the pump to the bedside, prepares to plug the pump cord into the wall,
and notes that no receptacle is available in the wall socket. The nurse should
take which action?
a) Initiate the intravenous line without the use of a pump.
b) Contact the electrical maintenance department for assistance.
c) Plug in the pump cord in the available plug above the room sink.
d) Use an extension cord from the nurses' lounge for the pump plug. Right
Ans - b) Contact the electrical maintenance department for assistance.
Rationale: Electrical equipment must be maintained in good working order
and should be grounded; otherwise it presents a physical hazard. An
intravenous line that contains a dose of potassium chloride should be
administered by an infusion pump. The nurse needs to use hospital resources
for assistance. A regular extension cord should not be used because it poses a
risk for fire. Use of electrical appliances near a sink also presents a hazard.
The nurse obtains a prescription from a health care provider to restrain a
client and instructs an unlicensed assistive personnel (UAP) to apply the
safety device to the client. Which observation by the nurse indicates unsafe
application of the safety device by the UAP?
a) Placing a safety knot in the safety device straps
b) Safely securing the safety device straps to the side rails
, c) Applying safety device straps that do not tighten when force is applied
against them
d) Securing so that two fingers can slide easily between the safety device and
the client's skin Right Ans - b) Safely securing the safety device straps to
the side rails
Rationale: The safety device straps are secured to the bed frame and never to
the side rail to avoid accidental injury in the event that the side rail is
released. A half-bow or safety knot should be used for applying a safety device
because it does not tighten when force is applied against it and it allows quick
and easy removal of the safety device in case of an emergency. The safety
device should be secure, and one or two fingers should slide easily between
the safety device and the client's skin.
The nurse is reviewing a plan of care for a client with an internal radiation
implant. Which intervention if noted in the plan indicates the need for
revision of the plan?
a) Wearing gloves when emptying the client's bedpan
b) Keeping all linens in the room until the implant is removed
c) Wearing a lead apron when providing direct care to the client
d) Placing the client in a semiprivate room at the end of the hallway Right
Ans - d) Placing the client in a semiprivate room at the end of the hallway
Rationale: A private room with a private bath is essential if a client has an
internal radiation implant. This is necessary to prevent accidental exposure of
other clients to radiation. The remaining options identify accurate
interventions for a client with an internal radiation implant and protect the
nurse from exposure.
The nurse enters a client's room and finds that the wastebasket is on fire. The
nurse immediately assists the client out of the room. What is the next nursing
action?
a) Call for help.
b) Extinguish the fire.
c) Activate the fire alarm.
d) Confine the fire by closing the room door. Right Ans - d) Confine the fire
by closing the room door.
