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Safety HESI prep Adult Care Questions and Answers
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Safety HESI prep Adult Care Questions and Answers The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which ...

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  • January 24, 2024
  • 52
  • 2023/2024
  • Exam (elaborations)
  • Questions & answers

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  • safety hesi prep adult care questions and answers

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Safety HESI prep Adult Care Questions and Answers
The nurse has just assisted a client back to bed after a fall. The nurse and health
care provider have assessed the client and have determined that the client is not
injured. After completing the incident report, the nurse should implement which
action next?


a) Reassess the client.
b) Conduct a staff meeting to describe the fall.
c) Document in the nurse's notes that an incident report was completed.
d) Contact the nursing supervisor to update information regarding the fall.
a) Reassess the client.


Rationale: After a client's fall, the nurse must frequently reassess the client because
potential complications do not always appear immediately after the fall. The client's fall
should be treated as private information and shared on a "need to know" basis.
Communication regarding the event should involve only the individuals participating in
the client's care. An incident report is a problem-solving document; however, its
completion is not documented in the nurse's notes. If the nursing supervisor has been
made aware of the incident, the supervisor will contact the nurse if status update is
necessary.
A client is being weaned from parenteral nutrition (PN), also known as total
parenteral nutrition, and is expected to begin taking solid food today. The
ongoing solution rate has been 100 mL/hour. The nurse anticipates that which
prescription regarding the PN solution will accompany the diet prescription?


a) Discontinue the PN.
b) Decrease PN rate to 50 mL/hour.
c) Start 0.9% normal saline at 25 mL/hour.
d) Continue current infusion rate prescriptions for PN.
b) Decrease PN rate to 50 mL/hour.


Rationale: When a client begins eating a regular diet after a period of receiving PN, the
PN is decreased gradually. PN that is discontinued abruptly can cause hypoglycemia.
Clients often have anorexia after being without food for some time, and the digestive
tract also is not used to producing the digestive enzymes that will be needed. Gradually
decreasing the infusion rate allows the client to remain adequately nourished during the
transition to a normal diet and prevents the occurrence of hypoglycemia. Even before
clients are started on a solid diet, they are given clear liquids followed by full liquids to
further ease the transition. A solution of normal saline does not provide the glucose

,needed during the transition of discontinuing the PN and could cause the client to
experience hypoglycemia.
The nurse is preparing to change the parenteral nutrition (PN) solution bag and
tubing. The client's central venous line is located in the right subclavian vein. The
nurse asks the client to take which essential action during the tubing change?


a) Breathe normally.
b) Turn the head to the right.
c) Exhale slowly and evenly.
d) Take a deep breath, hold it, and bear down.
d) Take a deep breath, hold it, and bear down.

Rationale: The client should be asked to perform the Valsalva maneuver during tubing
changes. This helps avoid air embolism during tubing changes. The nurse asks the
client to take a deep breath, hold it, and bear down. If the intravenous line is on the
right, the client turns his or her head to the left. This position increases intrathoracic
pressure. Breathing normally and exhaling slowly and evenly are inappropriate and
could enhance the potential for an air embolism during the tubing change.
The nurse is preparing to hang fat emulsion (lipids) and notes that fat globules
are visible at the top of the solution. The nurse should take which action?

a) Rolls the bottle of solution gently
b) Obtains a different bottle of solution
c) Shakes the bottle of solution vigorously
d) Runs the bottle of solution under warm water
b) Obtains a different bottle of solution

Rationale: Fat emulsion (lipids) is a white, opaque solution administered intravenously
during parenteral nutrition therapy to prevent fatty acid deficiency. The nurse should
examine the bottle of fat emulsion for separation of emulsion into layers of fat globules
or for the accumulation of froth. The nurse should not hang a fat emulsion if any of
these are observed and should return the solution to the pharmacy. Therefore the
remaining options are inappropriate actions.
The nurse is preparing to initiate an intravenous line containing a high dose of
potassium chloride and plans to use an intravenous infusion pump. The nurse
brings the pump to the bedside, prepares to plug the pump cord into the wall, and
notes that no receptacle is available in the wall socket. The nurse should take
which action?

a) Initiate the intravenous line without the use of a pump.
b) Contact the electrical maintenance department for assistance.
c) Plug in the pump cord in the available plug above the room sink.
d) Use an extension cord from the nurses' lounge for the pump plug.
b) Contact the electrical maintenance department for assistance.

,Rationale: Electrical equipment must be maintained in good working order and should
be grounded; otherwise it presents a physical hazard. An intravenous line that contains
a dose of potassium chloride should be administered by an infusion pump. The nurse
needs to use hospital resources for assistance. A regular extension cord should not be
used because it poses a risk for fire. Use of electrical appliances near a sink also
presents a hazard.
The nurse obtains a prescription from a health care provider to restrain a client
and instructs an unlicensed assistive personnel (UAP) to apply the safety device
to the client. Which observation by the nurse indicates unsafe application of the
safety device by the UAP?

a) Placing a safety knot in the safety device straps
b) Safely securing the safety device straps to the side rails
c) Applying safety device straps that do not tighten when force is applied against
them
d) Securing so that two fingers can slide easily between the safety device and the
client's skin
b) Safely securing the safety device straps to the side rails

Rationale: The safety device straps are secured to the bed frame and never to the side
rail to avoid accidental injury in the event that the side rail is released. A half-bow or
safety knot should be used for applying a safety device because it does not tighten
when force is applied against it and it allows quick and easy removal of the safety
device in case of an emergency. The safety device should be secure, and one or two
fingers should slide easily between the safety device and the client's skin.
The nurse is reviewing a plan of care for a client with an internal radiation
implant. Which intervention if noted in the plan indicates the need for revision of
the plan?

a) Wearing gloves when emptying the client's bedpan
b) Keeping all linens in the room until the implant is removed
c) Wearing a lead apron when providing direct care to the client
d) Placing the client in a semiprivate room at the end of the hallway
d) Placing the client in a semiprivate room at the end of the hallway

Rationale: A private room with a private bath is essential if a client has an internal
radiation implant. This is necessary to prevent accidental exposure of other clients to
radiation. The remaining options identify accurate interventions for a client with an
internal radiation implant and protect the nurse from exposure.
The nurse enters a client's room and finds that the wastebasket is on fire. The
nurse immediately assists the client out of the room. What is the next nursing
action?

a) Call for help.
b) Extinguish the fire.

, c) Activate the fire alarm.
d) Confine the fire by closing the room door.
d) Confine the fire by closing the room door.

Rationale: The order of priority in the event of a fire is to rescue the clients who are in
immediate danger. The next step is to activate the fire alarm. The fire then is confined
by closing all doors and, finally, the fire is extinguished.

RACE- rescue, alarm, confine, extinguish
PASS- pull the pin, aim at the base, squeeze the handle, sweep side to side.
A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old
child has just ingested liquid furniture polish. The nurse would direct the mother
to take which immediate action?


a) Induce vomiting.
b) Call an ambulance.
c) Call the Poison Control Center.
d) Bring the child to the emergency department.
c) Call the Poison Control Center.


Rationale: If a poisoning occurs, the Poison Control Center should be contacted
immediately. Vomiting should not be induced if the victim is unconscious or if the
substance ingested is a strong corrosive or petroleum product. Bringing the child to the
emergency department or calling an ambulance would not be the initial action because
this would delay treatment. The Poison Control Center may advise the mother to bring
the child to the emergency department and, if this is the case, the mother should call an
ambulance.
The nurse develops a plan of care for a client with deep vein thrombosis. Which
client position or activity in the plan should be included?

a) Out-of-bed activities as desired
b) Bed rest with the affected extremity kept flat
c) Bed rest with elevation of the affected extremity
d) Bed rest with the affected extremity in a dependent position
c) Bed rest with elevation of the affected extremity


Rationale: For the client with deep vein thrombosis, elevation of the affected leg
facilitates blood flow by the force of gravity and also decreases venous pressure, which
in turn relieves edema and pain. Bed rest is indicated to prevent emboli and to prevent
pressure fluctuations in the venous system that occur with walking.
The nurse is caring for a client who is 1 day postoperative for a total hip
replacement. Which is the best position in which the nurse should place the
client?

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