Fundamentals RN Exit Hesi 2 Q&A 2022
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse
is at greatest risk for a ... [Show More] malpractice judgment?
A) A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes.
B) The nurse assigned to care for the client who was at lunch at the time of the fall.
C) The nurse who transferred the client to the chair when the fall occurred.
D) The charge nurse who completed rounds 30 minutes before the fall occurred. - ANSC) The nurse who transferred the client to the chair when the fall occurred
The four elements of malpractice are: breach of duty owed, failure to adhere to the
recognized standard of care, direct causation of injury, and evidence of actual injury.
The hip fracture is the actual injury and the standard of care was "frequent monitoring."
(C) implies that duty was owed and the injury occurred while the nurse was in charge of
the client's care. There is no evidence of negligence in (A, B, and D)
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood
pressure with a cuff that is too small, but the blood pressure reading obtained is within
the client's usual range. What action is most important for the nurse to implement?
A) Tell the UAP to use a larger cuff at the next scheduled assessment.
B) Reassess the client's blood pressure using a larger cuff.
C) Have the unit educator review this procedure with the UAPs.
D) Teach the UAP the correct technique for assessing blood pressure. - ANS-B)
Reassess the client's blood pressure using a larger cuff
The most important action is to ensure that an accurate BP reading is obtained. The
nurse should reassess the BP with the correct size cuff (B). Reassessment should not
be postponed (A). Though (C and D) are likely indicated, these actions do not have the
priority of (B).
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is
essential to the client's nursing care?
A) Massage any reddened areas for at least five minutes.
B) Encourage active range of motion exercises on extremities.
C) Position the client laterally, prone, and dorsally in sequence.
D) Gently lift the client when moving into a desired position. - ANS-D) Gently lift the
client when moving into a desired position
To avoid shearing forces when repositioning, the client should be lifted gently across a
surface (D). Reddened areas should not be massaged (A) since this may increase the
damage to already traumatized skin. To control pain and muscle spasms, active range
of motion (B) may be limited on the affected leg. The position described in (C) is
contraindicated for a client with a fractured left hip.
A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while
ambulating. Based on these findings, which intervention should the nurse implement
first?
A) Assist the ambulating client back to the bed.
B) Encourage the client to ambulate to resolve pneumonia.
C) Obtain a prescription for portable oxygen while ambulating.
D) Move the oximetry probe from the finger to the earlobe. - ANS-A) Assist the
ambulating client back to the bed
An oxygen saturation below 90% indicates inadequate oxygenation. First, the client
should be assisted to return to bed (A) to minimize oxygen demands. Ambulation
increases aeration of the lungs to prevent pooling of respiratory secretions, but the
client's activity at this time is depleting oxygen saturation of the blood, so (B) is
contraindicated. Increased activity increases respiratory effort, and oxygen may be
necessary to continue ambulation (C), but first the client should return to bed to rest.
Oxygen saturation levels at different sites should be evaluated after the client returns to
bed (D).
During the initial morning assessment, a male client denies dysuria but reports that his
urine appears dark amber. Which intervention should the nurse implement?
A) Provide additional coffee on the client's breakfast tray.
B) Exchange the client's grape juice for cranberry juice.
C) Bring the client additional fruit at mid-morning.
D) Encourage additional oral intake of juices and water. - ANS-D) Encourage additional
oral intake of juices and water
Dark amber urine is characteristic of fluid volume deficit, and the client should be
encouraged to increase fluid intake (D). Caffeine, however, is a diuretic (A), and may
worsen the fluid volume deficit. Any type of juice will be beneficial (B), since the client is
not dysuric, a sign of an urinary tract infection. The client needs to restore fluid volume
more than solid foods (C).
The nurse notices that the mother a 9-year-old Vietnamese child always looks at the
floor when she talks to the nurse. What action should the nurse take?
A) Talk directly to the child instead of the mother.
B) Continue asking the mother questions about the child.
C) Ask another nurse to interview the mother now.
D) Tell the mother politely to look at you when answering. - ANS-B) Continue asking the
mother questions about the child... [Show Less]
