HESI RN FUNDAMENTALS
1. When turning an immobile bedridden client without assistance, which action
by the nurse best ensures client safety?
A. Securely
... [Show More] 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. [Show Less]
