HESI Fundamentals Version 1 |Best Rated Questions and Answers
1. The nurse is providing wound care to a client with stage 3 pressure ulcer that has a
... [Show More] large amount of eschar. The wound care prescription states “clean the wound and then apply collagenase. ” collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the nurse cleanse the pressure ulcer?
A. Lightly coat the wound with povidone-iodine solution
B. Irrigate the wound with sterile normal saline
C. Flush the wound with sterile hydrogen peroxide
D. Remove the eschar with a wet-to-dry dressing
2. A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?
A. Document the client’s circadian rhythms
B. Assess for flushed, warm skin regularly
C. Measure temperature at regular intervals
D. Vary sites for temperature measurement
3. When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first?
A. Position the client supine for a few minutes
B. Assist the client to stand at the bedside
C. Apply the blood pressure cuff securely
D. Record the client’s pulse rate and rhythm
4. The nurse is caring for a hospitalized client who was placed in restraints due to confusion. The family removes the restraints while they are with client. When the family leaves, what action should the nurse take first?
A. Apply the restraints to maintain the client’s safety.
B. Reassess the client to determine the need for continuing restraints.
C. Document the time the family left and continue to monitor the client.
D. Call the healthcare provider for a new prescription.
5. A client who has been taking diuretics for premenstrual swelling reports muscle weakness. Which serum electrolyte value should the nurse report to the healthcare provider?
A. Potassium 3. 1mEq/L (3. 1 mmil/L)
B. Sodium 142 mEq/L (142 mmol/L)
C. Total calcium 9. 2 mg/dl (2. 3 mmol/L)
D. Chloride 98 mEq/L (98 mmil/L)
6. The nurse is caring for a male client with diminished circulation in the lower extremities. The client washes his feet in the shower, but is unable to bend safely to dry his feet. While drying the client’s feet, the nurse should emphasize the need to thoroughly dry which area of the feet?
A. Between the toes.
B. Around the ankles.
C. On dorsal surfaces
D. Over the heels.
7. A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? [Show Less]