An adult has a coagulation time of 20 minutes. The nurse should observe the client for which of the following?

Questions 54

HESI RN

HESI RN Test Bank

HESI Fundamentals Quizlet Questions

Question 1 of 9

An adult has a coagulation time of 20 minutes. The nurse should observe the client for which of the following?

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 2 of 9

A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?

Correct Answer: D

Rationale: The correct action for the nurse to take first in this situation is to compare the current blood pressure reading with the client's previously documented readings. This comparison will provide valuable information about what is normal for this specific client, helping to determine if the current reading represents a significant change or if it falls within the client's usual range. This step is essential for appropriate decision-making and planning further care.

Question 3 of 9

What action should be implemented to prevent the formation of a sacral ulcer for an immobile client?

Correct Answer: B

Rationale: Positioning the client prone with a small pillow below the diaphragm helps maintain proper alignment and provides optimal pressure relief over the sacral area, reducing the risk of developing a pressure ulcer. This position redistributes pressure away from bony prominences, such as the sacrum, which is crucial in preventing ulcer formation in immobile clients.

Question 4 of 9

In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible?

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 5 of 9

The client with chronic obstructive pulmonary disease (COPD) is being taught pursed-lip breathing by the nurse. What is the purpose of this technique?

Correct Answer: C

Rationale: Pursed-lip breathing is used to increase the amount of carbon dioxide exhaled (C) in clients with chronic obstructive pulmonary disease (COPD). By doing so, it helps prevent air trapping and enhances gas exchange, ultimately improving respiratory efficiency. While removing secretions (A), reducing air trapping (B), and slowing the respiratory rate (D) can be associated benefits, the primary goal of pursed-lip breathing is to optimize carbon dioxide elimination and enhance breathing mechanics.

Question 6 of 9

When assisting a client with right-sided hemiplegia to get into a wheelchair, how should the nurse position the wheelchair?

Correct Answer: A

Rationale: Positioning the wheelchair on the left side of the bed facing the foot of the bed is the correct approach when assisting a client with right-sided hemiplegia. Placing the wheelchair on the left side allows the client to stand on their unaffected foot and pivot to sit down safely. This positioning facilitates a smoother transfer and helps maintain the client's stability during the process.

Question 7 of 9

A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs?

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 8 of 9

Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed, and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse take in response to this situation?

Correct Answer: C

Rationale: In this scenario, the nurse acted appropriately by withholding the medication, consulting with the healthcare provider, and administering the newly prescribed dose, albeit with a delay. The correct course of action for the nurse is to document all these events in the nurse's notes. Documenting the sequence of actions taken is crucial for maintaining an accurate record of the client's care, ensuring transparency, and providing essential information for future reference and continuity of care.

Question 9 of 9

A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment because she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

Correct Answer: C

Rationale: The correct answer is C. For droplet precautions, such as in the case of pertussis, a standard face mask is sufficient for protection. Particulate filter masks are required for airborne precautions, not for droplet precautions. Therefore, the UAP can proceed with taking the vital signs using a standard mask without the need for a particulate filter mask. It is important for healthcare workers to understand the appropriate use of personal protective equipment based on the type of precautions in place to provide safe and effective care to clients.

Access More Questions!

HESI RN Basic


$89/ 30 days

HESI RN Premium


$150/ 90 days