HESI RN FUNDAMENTALS

1. When turning an immobile bedridden client 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.

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?