HESI RN FUNDAMENTALS
(75 QUESTIONS & ANSWERS,RATIONALE)
1. 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.
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.
2. 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
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.
, 3. 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
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.
4. 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.
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.
5. 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
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.
6. 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.
, 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 and should never place his or her arms around the nurse's
neck; this places undue stress on the nurse's neck and back and increases
the risk for a fall.
7.Which step(s) should the nurse take when administering ear drops to
an adult client? (Select all that apply.)
A. Place the client in a side-lying position.
B. Pull the auricle upward and outward.
C. Hold the dropper 6 cm above the ear canal.
D. Place a cotton ball into the inner canal.
E. Pull the auricle down and back.
Rationale:
The correct answers (A and B) are the appropriate administration of ear
drops. The dropper should be held 1 cm (½ inch) above the ear canal (C).
A cotton ball should be placed in the outermost canal (D). The auricle is
pulled down and back for a child younger than 3 years of age, but not an
adult (E).
8.The nurse is instructing a client in the proper use of a metered-dose
inhaler. Which instruction should the nurse provide the client to ensure the
optimal benefits from the drug?
A. "Fill your lungs with air through your mouth
and then compress the inhaler."
B. "Compress the inhaler while slowly breathing
in through your mouth."
C. "Compress the inhaler while inhaling quickly
through your nose."
D. "Exhale completely after compressing the
inhaler and then inhale."
(75 QUESTIONS & ANSWERS,RATIONALE)
1. 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.
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.
2. 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
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.
, 3. 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
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.
4. 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.
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.
5. 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
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.
6. 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.
, 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 and should never place his or her arms around the nurse's
neck; this places undue stress on the nurse's neck and back and increases
the risk for a fall.
7.Which step(s) should the nurse take when administering ear drops to
an adult client? (Select all that apply.)
A. Place the client in a side-lying position.
B. Pull the auricle upward and outward.
C. Hold the dropper 6 cm above the ear canal.
D. Place a cotton ball into the inner canal.
E. Pull the auricle down and back.
Rationale:
The correct answers (A and B) are the appropriate administration of ear
drops. The dropper should be held 1 cm (½ inch) above the ear canal (C).
A cotton ball should be placed in the outermost canal (D). The auricle is
pulled down and back for a child younger than 3 years of age, but not an
adult (E).
8.The nurse is instructing a client in the proper use of a metered-dose
inhaler. Which instruction should the nurse provide the client to ensure the
optimal benefits from the drug?
A. "Fill your lungs with air through your mouth
and then compress the inhaler."
B. "Compress the inhaler while slowly breathing
in through your mouth."
C. "Compress the inhaler while inhaling quickly
through your nose."
D. "Exhale completely after compressing the
inhaler and then inhale."
