HESI FUNDAMENTALS NCLEX PREP GREEN BOOK
When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety?
A.
Securely grasp the client's arm and leg.
B.
Put bed rails up on the side of bed opposite from the nurse.
C.
Correctly position and ...
HESI FUNDAMENTALS
NCLEX PREP GREEN
BOOK
When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety?
A.
Securely grasp the client's arm and leg.
B.
Put bed rails up on the side of bed opposite from the nurse.
C.
Correctly position and use a turn sheet.
D.
Lower the head of the client's bed slowly.
B.
Rationale: Because the nurse can only stand on one side of the bed, bed rails should be up on the opposite side to ensure that the client does not fall out of bed. Option A can cause client injury to the skin or joint. Options C and D are useful techniques while turning a client but have less priority in terms of safety than use of the bed r
The nurse identifies a potential for infection in a client with partial-thickness (second-degree) and full-thickness (third-degree) burns. What action has the highest priority in decreasing the client's risk of infection?
A.
Administration of plasma expanders
B.
Use of careful handwashing technique
C.
Application of a topical antibacterial cream D.
Limiting visitors to the client with burns
B
Careful handwashing technique is the single most effective intervention for the prevention of contamination to all clients. Option A reverses the hypovolemia that initially accompanies burn trauma but is not related to decreasing the proliferation of infective organisms. Options C and D are recommended by various
burn centers as possible ways to reduce the chance of infection. Option B is a proven technique to prevent infection
The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most
reliable indicator of chronic protein malnutrition?
A.
Low serum albumin level
B.
Low serum transferrin level
C.
High hemoglobin level
D.
High cholesterol level
A
Rationale:Long-term protein deficiency is required to cause significantly lowered serum albumin levels. Albumin is made by the liver only when adequate amounts of amino acids (from protein breakdown) are available. Albumin has a long half-
life, so acute protein loss does not significantly alter serum levels. Option B is a serum protein with a half-life of only 8 to 10 days, so it will drop with an acute protein deficiency. Options C and D are not clinical measures of protein malnutrition.
In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next?
A.
Witness the client's signature to the permit.
B. Answer the client's questions about the surgery.
C.
Inform the surgeon the client has questions about the surgery.
D.
Reassure the client that the surgeon will answer any questions before the anesthesia is administered.
C
Rationale:It is the surgeon’s responsibility to explain the procedure to the client and obtain the client’s signature on the permit. Although the nurse can witness an
operative permit, the procedure must first be explained by the health care provider or surgeon, including answering the client’s questions. The client’s questions should be addressed before the permit is signed.
The nurse is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery?
A.
Taking birth control pills for the past 2 years
B.
Taking anticoagulants for the past year
C.
Recently completing antibiotic therapy
D.
Having taken laxatives PRN for the last 6 months
B
Rationale:Anticoagulants increase the risk for bleeding during surgery, which can pose a threat for the development of surgical complications. The health care provider should be informed that the client is taking these drugs. Although clients who take birth control pills may be more susceptible to the development of thrombi, such problems usually occur postoperatively. A client with option C or D is at less of a surgical risk than with option B.
When assisting a client from the bed to a chair, which procedure is best for the nurse to follow? A.
Place the chair parallel to the bed, with its back toward the head of the bed and assist the client in moving to the chair.
B.
With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair.
C.
Assist the client to a standing position by gently lifting upward, underneath the axillae.
D.
Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.
B
Rationale:Option B describes the correct positioning of the nurse and affords the nurse a wide base of support while stabilizing the client’s knees when assisting to a standing position. The chair should be placed at a 45-degree angle to the bed, with the back of the chair toward the head of the bed. Clients should never be lifted under the axillae; this could damage nerves and strain the nurse’s back. The client should be instructed to use the arms of the chair and should never place his
or her arms around the nurse’s neck; this places undue stress on the nurse’s neck and back and increases the risk for a fall.
Which steps should the nurse take when administering ear drops to an adult client? (Select all that apply. )
A.
Place the client in a side-lying position.
B.
Pull the auricle upward and outward.
C.
Hold the dropper 6 cm above the ear canal.
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