HESI Missed Questions
A nurse provides instruction to a new nursing assistant regarding the application of a restraint to a client. The nurse watches as the nursing assistant applies the restraint. What observation tells the nurse that the nursing assistant is using correct procedure? The assistant applies a tie knot in the restraint strap. The assistant secures the restraint in such a way that it is impossible to slip a finger between the restraint and the client's skin. The assistant applies the restraint so that the strap does not tighten when force is applied against it. The assistant attaches the restraint straps securely to the siderails.
The assistant applies the restraint so that the strap does not tighten when force is applied against it.
Wrist restraints have been prescribed for a client who is constantly pulling at his gastrostomy tube. Which findings does the nurse, developing a care plan, recognize as unexpected outcomes related to the use of restraints? Select all that apply. The client is unable to reach the gastrostomy tube with his hands. The client slips his hand from its restraint and pulls at his gastrostomy tube. The client becomes agitated. The client verbalizes the reason for the restraints. The skin under the restraint is red. The client's left hand is pale and cold.
The client slips his hand from its restraint and pulls at his gastrostomy tube. The client becomes agitated. The skin under the restraint is red. The client's left hand is pale and cold.
A nurse educator is providing inservice sessions to the nursing staff regarding employee safety and the prevention of occupationally acquired HIV infection. Which of the following precautions does the nurse instruct the nursing staff to take as a means of preventing accidental needlesticks? Select all that apply. The use of latex gloves The use of needleless devices Disposal of needles in special puncture-resistant containers The use of shielded needles The use of recessed needles
The use of needleless devices Correct Disposal of needles in special puncture-resistant containers Correct The use of shielded needles Correct
A nurse prepares to teach a client with chronic vertigo about safety measures to help prevent exacerbation of symptoms and injury. Which instructions should the nurse provide to the client? Select all that apply. "Use public transportation as much as possible." "Change positions slowly." "Drive your car only if you're not feeling dizzy." "Remove clutter from your home." "Turn your head slowly when someone speaks to you."
"Change positions slowly." "Remove clutter from your home."
A home health nurse has instructed a client about safety measures during the use of an oxygen concentrator in the home. Which statement by the client indicates to the nurse that the client has understood the directions? Select all that apply. "I need to keep the oxygen concentrator as close to the wall as possible or put it in a corner." "I can use my electric razor while I'm using oxygen." "I have to keep the oxygen concentrator out of direct sunlight." "I have to tell everyone that they can't smoke or have an open flame within 10 feet (3 meters) of the oxygen concentrator." "I need to follow the oxygen prescription exactly."
"I have to keep the oxygen concentrator out of direct sunlight." Correct "I have to tell everyone that they can't smoke or have an open flame within 10 feet (3 meters) of the oxygen concentrator." Correct "I need to follow the oxygen prescription exactly." Correct
An emergency department (ED) nurse is triaging victims of an explosion at a nearby manufacturing plant. To which victims should the nurse assign the emergent (priority 1) designation? Select all that apply. A victim with a limb amputation A victim who is bleeding profusely from a head laceration A victim who is alert but complaining of loss of vision A victim who is dazed and staggering around the other victims A victim who has sustained minor bruising of an arm and the lower legs
A victim with a limb amputation Correct A victim who is bleeding profusely from a head laceration Correct A victim who is alert but complaining of loss of vision Correct
A client with an infection is receiving antibiotics by way of intramuscular (IM) injection. The client is also receiving subcutaneous (SC) injections of heparin. Which precaution does the nurse understand is most appropriate to help ensure the safety of this client? Applying prolonged pressure to the sites of the IM and SC sites Doubling the dose of anticoagulant Applying a pressure bandage to the site after each IM injection Decreasing the sizes of the needles used for the IM and SC injections
Applying prolonged pressure to the sites of the IM and SC sites
Which actions should the nurse take in the event of an accidental poisoning? Select all that apply. Assessing the client's airway patency, breathing, and circulation Inducing vomiting if a household cleaner has been ingested Determining the type and amount of substance ingested Saving vomitus for laboratory analysis Placing the client in the supine position Removing any visible materials from the nose and mouth
Assessing the client's airway patency, breathing, and circulation Correct Determining the type and amount of substance ingested Correct Saving vomitus for laboratory analysis Correct Removing any visible materials from the nose and mouth
Which of the following points should the nurse include when documenting information about a client who is wearing wrist restraints? Select all that apply. Circulatory and neurovascular status of the restrained extremities The date and time of application of the restraint Skin integrity of the restrained body part The procedure used in applying the restraint The client's temperature The client's 24-hour urine output
Circulatory and neurovascular status of the restrained extremities Correct The date and time of application of the restraint Correct Skin integrity of the restrained body part Correct The procedure used in applying the restraint Correct
An adolescent client asks the nurse questions about the transmission of the Epstein-Barr virus (infectious mononucleosis). By which route should the nurse tell the client that the disease is transmitted? Fecal-oral Airborne particles Close intimate contact Respiratory droplets
Close intimate contact
A nurse is discussing accident prevention with the family of an older client who is being discharged from the hospital after hip surgery. This client has a tendency to be forgetful. Which items in the home increase the client's risk for injury? Select all that apply. Smoke and carbon monoxide detectors A water heater thermostat adjusted to a low setting Cooking equipment such as a stove A nightlight in the bathroom Elevated toilet seat with armrests Common household objects such as doormats
Cooking equipment such as a stove Common household objects such as doormats
A community health nurse working in a school setting is concerned because parents are not participating in health activities designed to promote child safety. In this situation, the most appropriate initial action is: Implementing a child safety program Determining the appropriateness of the planned health activity Performing an analysis of health problems related to child safety Planning a focused child safety program
Determining the appropriateness of the planned health activity
Which of the following actions are in keeping with the principles of standard precautions? Select all that apply. Discarding needles in puncture-resistant containers Wearing a gown and gloves when changing the linens on the bed of a client with a draining lesion of the leg Handwashing before removal of a pair of soiled gloves Cleaning of blood spills with soap and warm water Wearing a face shield as a part of the protective garb during a wound irrigation Handwashing between client contacts
Discarding needles in puncture-resistant containers Correct Wearing a gown and gloves when changing the linens on the bed of a client with a draining lesion of the leg Correct Wearing a face shield as a part of the protective garb during a wound irrigation Correct
A home health nurse is visiting a client with tuberculosis (TB). Which action by the client tells the nurse that the client understands the necessary respiratory precautions to be taken at home? Disposing of contaminated tissues in a container with a leak-proof bag Keeping the house closed up to minimize the spread of disease Wearing an oxygen mask at all times Staying secluded in the bedroom
Disposing of contaminated tissues in a container with a leak-proof bag
A nurse educator is providing an inservice program to emergency department nurses about the signs of inhalation anthrax. The nurse educator tells the nurses that one early indication of inhalation anthrax is: Flulike symptoms Hemorrhage Signs of shock Respiratory distress
Flulike symptoms
A nurse who is preparing to leave the room of a client who is under airborne precautions needs to remove the following protective items: gloves, gown, mask, and goggles. Place in order of priority the items that need to be removed.
Gloves Goggles Gown Mask
A nurse is assigned to care for a client with an infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator that requires frequent suctioning. While gathering the needed supplies before entering the client's room, which necessary protective items does the nurse obtain? Select all that apply. Gloves Face shield Gown Shoe protectors Mask
Gloves Correct Face shield Correct Gown Correct
The nursing staff in an emergency department is reviewing and updating the disaster preparedness plan. The staff members, discussing ways to help prevent the transmission of smallpox, know that this infection is transmitted by which route? Enteric Through open wounds Gastrointestinal Inhalation
Inhalation
Which of these interventions does a nurse manager, reviewing infection control interventions with the nursing staff, tell the staff will reduce reservoirs of infection? Select all that apply. Keeping bedside table surfaces clean and dry Emptying urinary drainage systems (Foley catheter drainage) on each shift unless prescribed otherwise by a physician Placing tissues and soiled dressings in paper bags Using soap and water to remove drainage, dried secretions, or excess perspiration from a client's skin Changing dressings that become wet or soiled Placing capped needles and syringes in puncture-resistant containers
Keeping bedside table surfaces clean and dry Correct Emptying urinary drainage systems (Foley catheter drainage) on each shift unless prescribed otherwise by a physician Correct Using soap and water to remove drainage, dried secretions, or excess perspiration from a client's skin Correct Changing dressings that become wet or soiled Correct
ID: 9476942577 A home care nurse is visiting an older client who has been recovering from a mild brain attack (stroke) affecting her left side. The client lives alone but receives regular assistance from her daughter and son, who both live within 10 miles. Which of the following actions should the nurse take to assess the client's safety risk? Select all that apply. Looking for any hazards in the home environment Asking a family member to move in with the client until her recovery is complete Assessing the client's visual acuity Observing the client's gait and posture Requesting that the client transfer to an assisted living environment for at least 1 month Evaluating the client's muscle strength
Looking for any hazards in the home environment Correct Assessing the client's visual acuity Correct Observing the client's gait and posture Correct Evaluating the client's muscle strength Correct
A community health nurse is providing information to local residents about the transmission of anthrax. Through which body systems does the nurse tell the residents that anthrax can be contracted? Select all that apply. Lungs Lymphatic Gastrointestinal Skin Urinary Immune
Lungs Correct Gastrointestinal Correct Skin Correct
A nurse caring for a client with leukemia who is undergoing chemotherapy reviews the latest laboratory results and notes that the neutrophil count is below 500 cells/mm3 (0.5 x 109/L). Which of the following interventions does the nurse implement on the basis of this finding? Select all that apply. Avoiding overinflation of the blood pressure cuff and rotating the cuff among several sites when measuring the blood pressure Requiring the client to use an electric shaver rather than a razor Maintaining sterile occlusion of intravenous (IV) catheters Monitoring the client's oral temperature Providing a soft toothbrush for oral care Performing meticulous skin decontamination before venipuncture
Maintaining sterile occlusion of intravenous (IV) catheters Monitoring the client's oral temperature Performing meticulous skin decontamination before venipuncture
The nurse plans to wear this protective mask (see figure) when caring for clients with certain disorders. What are these disorders? Select all that apply. Scabies Hepatitis A Meningococcal pneumonia Pharyngeal diphtheria Streptococcal pharyngitis Tuberculosis
Meningococcal pneumonia Correct Pharyngeal diphtheria Correct Streptococcal pharyngitis Correct
Acccording to the Federal Emergency Management Agency (FEMA) description of the phases of disaster management, in which phase are the available resources for the care of infants, older clients, the disabled, and people with chronic health problems addressed? Recovery Mitigation Response Preparedness
Mitigation
A nurse leading an educational session about terrorism for members of the community is discussing anthrax. Which of the following pieces of information should the nurse provide to the group attending the session? Select all that apply. One way that anthrax can be contracted is through the skin. Anthrax can be transmitted from person to person. No vaccine to prevent anthrax is available. A blood test is available for the detection of anthrax. Anthrax is never fatal.
One way that anthrax can be contracted is through the skin. Correct A blood test is available for the detection of anthrax. Correct
A nurse, preparing a sterile field on which to perform a dressing change, places the sterile drape on the overbed table. Which of these actions on the part of the nurse indicate correct understanding of the principles of aseptic technique? Select all that apply. Leaving the room to obtain a bottle of sterile normal saline solution Picking up a pair of sterile scissors from the sterile field with a sterile gloved hand Positioning the sterile field so that it remains in full view Holding the pair of sterile forceps below waist level area Pouring sterile wound cleansing solution into a sterile cup before donning sterile gloves Reaching across the sterile field to pick up a sterile gauze
Picking up a pair of sterile scissors from the sterile field with a sterile gloved hand Positioning the sterile field so that it remains in full view Pouring sterile wound cleansing solution into a sterile cup before donning sterile gloves
Which of the following actions are means of maintaining medical asepsis to reduce and prevent the spread of microorganisms? Select all that apply. Sterilizing contaminated items Applying a sterile gown and gloves Reapplying a sterile dressing Practicing hand hygiene Wearing clean gloves to prevent direct contact with blood or body fluids Routinely cleaning the hospital environment
Practicing hand hygiene Correct Wearing clean gloves to prevent direct contact with blood or body fluids Correct Routinely cleaning the hospital environment Correct
A nurse caring for a 9-month-old who has undergone repair of a cleft palate applies elbow restraints to the child. The mother visits her child and asks the nurse to remove the restraints. According to the guidelines for the use of restraints, what should the nurse do in response to the mother's request? Loosen the restraints after telling the mother that they may not be removed Remove both restraints Remove a restraint from one extremity Tell the mother that the restraints may not be removed
Remove a restraint from one extremity
A staff nurse caring for a client with a head injury notes that the client is restless and pulling at the intravenous (IV) line. The client's primary health care provider does not want to prescribe sedation, and the family has requested that the client not be restrained. Which action by the nurse is best? Telling the family that the application of wrist restraints is critical in preventing injury to the client Asking a nursing assistant to monitor the client Asking a family member to sit with the client Staying with the client and consulting with the nurse manager about the situation
Staying with the client and consulting with the nurse manager about the situation Correct
Which of the following safety guidelines should the nurse include in the plan of care for a client with an internal radiation implant? Select all that apply. Wear a lead shield when in the client's room. Allow children to visit the client as long as they are at least 12 years old. Limit visits from family to 60 minutes per day. Keep all bed linens and dressings in the client's room until the implant is removed. Wear a dosimeter film badge when in the client's room.
Wear a lead shield when in the client's room. Correct Keep all bed linens and dressings in the client's room until the implant is removed. Correct Wear a dosimeter film badge when in the client's room.
A nurse is preparing a chemotherapy infusion to be administered to a client with a diagnosis of Hodgkin's disease. Which precaution should the nurse take while working with this intravenous (IV) infusion? Wearing gloves, a mask, and a head covering Wearing gloves and a mask Wearing gloves and a gown Wearing gloves, a mask, and eye protection
Wearing gloves, a mask, and eye protection Correct
Which event would require a nurse to complete and file an incident report? The nurse determines that a client would benefit from the use of a walker to ambulate. When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor's blood pressure and takes the visitor to the emergency department for treatment. The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion pump is not working. A client has a seizure. I
When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor's blood pressure and takes the visitor to the emergency department for treatment.