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When turning an immobile bedridden client
... [Show More] 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.
(ANS- B.
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 r
The nurse identifies a potential for infection in a client with partial-thickness
(second-degree) and full-thickness (third-degree) burns. What action has the
highest priority in decreasing the client's risk of infection?
A.
Administration of plasma expanders
B.
Use of careful hand washing technique
C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns
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(ANS- B
Careful hand washing 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
HESI RN FUNDAMENTAL EXAM TEST
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as possible ways to reduce the chance of infection. Option B is a proven technique
to prevent infection
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
(ANS- A
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.
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.
HESI RN FUNDAMENTAL EXAM TEST
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B.
Answer the client's questions about the surgery.
C.
Inform the surgeon the client has questions about the surgery.
D [Show Less]