HESI Fundamentals Practice Exam /Latest 2022:2023/Q&A

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A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection? a) Thre... ad the IV catheter so that the hub rests at the insertion site b) Shave excess hair from around the insertion site c) Cleanse the site with hydrogen peroxide before IV catheter insertion d) Palpate the site carefully just before inserting the IV catheter (ANS - A Inserting the catheter up to the hub reduces the risk of contaminating along the length of the catheter what can increase the risk for infection at an iv site? What is used to clean the site? (ANS – -shaving excess hair around insertion site -palpating the site after cleansing b/c this can introduce micro-organisms -iodine or chlorhexidine to cleanse the agent before insertion A nurse is caring for a postoperative adult client who refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action? a) Request that a respiratory therapist discuss the technique for incentive spirometry b) Administer a pain medication to the client c) Chart the client's refusal to participate in health restorative activities d) Determine the reasons why the client is refusing the use the incentive spirometer (ANS - D *the first action of the nurse should be to use the nursing process and ASSESS the client first A nurse is preparing to administer ampicillin 40mg/kg/day PO divided in equal doses every 6 hours to a toddler who weighs 10 kg. Available is ampicillin oral suspension 125/5 mL. How many mL should the nurse administer per dose? (ANS – mg x kg/day = X 40 mg x 10 kg = 400 mg 400 / 4 = 100 mg per dose is desired 125 mg / 5 mL = 100 mg / X mL X = 4 A nurse is preparing to administer meperidine (Demerol) 80 mg IM from a 100 mg prefilled syringe. After the injection, which of the following is an appropriate action by the nurse? a) Return the unused portion to the pharmacy b) Have another nurse witness the disposal of the excess medication c) Place the syringe with the unused portion in a locked medication drawer d)Discard the unused medication in the sharps container (ANS - B meperidine is a controlled substance -the remaining medication should be wasted with the witness of another nurse A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? SATA a) Place the client in a negative pressure room b) wear gloves when assisting the client with oral care c) limit each visitor to 2 hr increments d) wear a surgical mask when providing care e) Use antimicrobial sanitizer for hand hygiene (ANS - A, B, E -limiting visitors is not necessary -N95 respirator mask should be worn to meet the requirements of airborne precautions A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the clients room c) clean contaminated surfaces in the clients room with a phenol solution d) have family members wear a gown and gloves when visiting (ANS - D *nurses are responsible for ensuring family members wear gown and gloves to prevent transmission of C. difficile spores -phenol solution does not kill C. difficile spores -nurse should use soap and water b/c alcohol hand sanitizer does not kill C. difficle spores -negative air-flow room not necessary A nurse is providing teaching to a client about techniques to promote sleep. Which of the following instructions should the nurse include in the teaching? a) Consume a light snack of carbohydrates at bedtime b) Drink warm tea at bedtime c) watch TV in bed util drowsy d) exercise 1 hr before bedtime (ANS - A -limit intake of fluids before bed to avoid nighttime voiding -limit stimulating activities while in bed such as watching tv -limit exercise before bed A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the client has developed phlebitis and removes the IV catheter. Which of the following actions should the nurse take next? a) place a warm compress over the IV site b) record the findings in the client's chart c) notify the client's primary care provider d) prepare to insert a new IV catheter (ANS - A The greatest risk to the client is further injury. The next action should take is to apply a warm compress over the IV site to decrease edema and client discomfort. A charge nurse is observing a newly hired nurse prepare a sterile field. Which of the following indicates to the charge nurse that the sterile field is contaminated? a) Outer edges of the sterile field is touching a bottle b) first fold is opened away from the body c) sterile objects are held above the waist d) sterile field is opened on a wet surface (ANS - D [Show More]

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