HESI Fundamentals Exam Test Bank - Nurselytic

Correct Answer: A

Rationale: In situations where a client is in the terminal stage of cancer and crying, it is essential for the nurse to provide comfort and support. Sitting with the client and holding their hand can offer a sense of presence and emotional support, showing empathy and understanding. Encouraging the client to talk about their feelings (choice
B) is also important, but initially, non-verbal support through physical presence can be comforting. Leaving the client alone to cry (choice
C) can make the client feel abandoned and unsupported during a vulnerable moment. Ignoring the client's crying (choice
D) is not appropriate and lacks compassion and empathy, which are crucial in end-of-life care.

Correct Answer: A

Rationale: A positive Chvostek's sign is a clinical indication of low calcium levels, known as hypocalcemia. This sign is elicited by tapping the facial nerve anterior to the ear, resulting in facial muscle twitching. The correct laboratory finding associated with a positive Chvostek's sign is decreased calcium. Elevated potassium (
Choice
B) is not typically associated with Chvostek's sign but can be seen in conditions like renal failure. Increased sodium (
Choice
C) is not directly related to Chvostek's sign and is more commonly associated with hypernatremia. Low hemoglobin (
Choice
D) is not the expected laboratory finding in a client with a positive Chvostek's sign; instead, it suggests anemia, which is unrelated to this clinical manifestation.

Correct Answer: D

Rationale: Maintaining sterile technique when handling a central venous catheter is crucial in preventing infections. This action helps minimize the introduction of pathogens into the catheter site, reducing the risk of contamination and subsequent infection. Changing the catheter dressing every 72 hours, while important, does not directly address the prevention of infection at the insertion site. Flushing the catheter with heparin solution daily helps prevent occlusion but does not primarily focus on infection prevention. Ensuring the catheter is clamped when not in use is essential for preventing air embolism but does not directly relate to infection control.

Correct Answer: A

Rationale: The correct answer is A: Hydrocolloid. Hydrocolloid dressings are recommended for stage 2 pressure injuries as they help maintain a moist wound environment, which supports the healing process. Gauze (choice
B) is not ideal for stage 2 pressure injuries as it can stick to the wound bed and disrupt the healing process. Transparent film dressings (choice
C) are more suitable for superficial wounds or as a secondary dressing. Alginate dressings (choice
D) are typically used for wounds with heavy exudate, which is not typically seen in stage 2 pressure injuries.

Correct Answer: A

Rationale: When a patient reports an inability to clear nasal passages, the appropriate action for the nurse to take is to use gentle suction to prevent tissue damage. Suctioning helps remove excess mucus or secretions without causing harm to the nasal tissues. Instructing the patient to blow their nose forcefully (
Choice
B) may exacerbate the issue and cause discomfort or injury. Placing a dry washcloth under the nose (
Choice
C) is not an effective intervention for clearing nasal passages. Inserting a cotton-tipped applicator into the back of the nose (
Choice
D) is not recommended as it can be invasive and may cause injury or discomfort to the patient.