HESI RN Fundamentals Exam 1

Extract:

Question 1 of 5

The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?

Correct Answer: C

Rationale: Inspecting tips ensures safety.

Question 2 of 5

Which intervention is most important for the nurse to implement before leaving a postoperative client with severe obstructive sleep apnea (OSA) alone?

A. Remove dentures or other oral appliance. B. Elevate the head of the bed to a 45-degree angle. C. Apply the client’s positive airway pressure device. D. Put and lock the side rails in place.

Correct Answer: C

Rationale: CPAP prevents airway collapse.

Question 3 of 5

The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

A. Gives the client a hug and says, 'It’s okay to cry when you are sad.' B. While touching the client’s forearm, asks, 'Would you like to talk about it?' C. I’m sorry to disturb you at a difficult time. This can wait until later.' D. This is a bad time. I can see you are upset. I can come back later.'

Correct Answer: B

Rationale: Empathy encourages communication.

Question 4 of 5

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

A. Active bowel sounds in the lower right quadrant. B. Contraction of the left pupil when light shines in the right eye. C. Basilar lung sounds that are diminished in the left lung. D. Capillary refill of 2 seconds in the lower right foot.

Correct Answer: C

Rationale: Abnormal findings are documented.

Question 5 of 5

The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client’s auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

A. Advise the UAP to hold the thermometer securely in place for a full three minutes. B. Use positive reinforcement to affirm that the procedure is being performed correctly. C. Demonstrate the correct technique for pulling the client’s auricle down and back. D. Remind the UAP to lubricate the thermometer before gently inserting it in the ear.

Correct Answer: B

Rationale: Up-and-back is correct for adults.

HESI RN Fundamentals Exam 1 | Nurselytic

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HESI RN

HESI RN