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HESI RN FUNDAMENTALS V1
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HESI RN FUNDAMENTALS V1
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HESI RN FUNDAMENTALS V1 EXAM TEST BANKWhat can a blood pressure cuff that's too narrow cause? - ANSWER: falsely elevated
BP reading
this insulin should be drawn up into the syringe first so it doesn't contaminate the
other type of insulin - ANSWER: regular
rumbling sounds heard on lung auscultation - ANSWER: rhonchi
this type of adventitious lung sounds can be more pronounced during expiration
than during inspiration - ANSWER: rhonchi
forced feeding, usually through a gastric tube - ANSWER: gavage
a tube passed into the stomach through the mouth - ANSWER: gastric tube
What portion of Maslow's hierarchy of needs has the highest priority? - ANSWER:
physiologic needs (air, water, food, shelter, activity, comfort)
this is the safest and surest way to verify a patient's identity - ANSWER: check the ID
band on wrist
What is the primary concern in the therapeutic environment? - ANSWER: patient
safety
What does fluid oscillation in the tubing of a chest drainage system indicate? -
ANSWER: system is working properly
What position should a nurse place a patient who has a Sengstaken-Blakemore tube?
- ANSWER: semi-Fowlers
How can a nurse elicit Trousseau's sign? - ANSWER: occluding the brachial or radial
artery
What indicates Trousseau's sign? - ANSWER: hand and finger spasms during
occlusion
What does Trousseau's sign suggest? - ANSWER: hypocalcemia
What is the appropriate needle size for adult blood transfusions? - ANSWER: 16 to
20G
,this type of pain is incapacitating and can't be relieved by drugs - ANSWER:
intractable pain
How can a consent for treatment be obtained in an emergency? - ANSWER: fax,
telephone (or other telegraphic means)
the unit of measurement of sound - ANSWER: decibel
this is required for any invasive procedure - ANSWER: informed consent
What must a patient do who can't write their name to give consent for treatment? -
ANSWER: make an X in the presence of two witnesses (such as a nurse, priest, or
physician)
this IM injection method seals the drug deep into the muscle - ANSWER: Z-track
method
this IM injection method minimizes skin irritation and staining - ANSWER: Z-track
method
What length needle is required for the Z-track IM injection method? - ANSWER: 1" or
longer
What acronym is often used in the event of a fire? - ANSWER: RACE (REMOVE the
patient, ACTIVATE the alarm, Attempt to CONTAIN the fire by closing the door,
EXTINGUISH the fire if it can be done safely)
Who should be assigned to a registered nurse to perform bedside care, such as
suctioning or drug administration? - ANSWER: LPN (or licensed vocational nurse)
What must be done if the patient cannot void? - ANSWER: bladder palpation to
assess for bladder distention
What side should the patient who uses a cane carry it on? - ANSWER: unaffected side
How should a patient use a cane? - ANSWER: advance it at the same time as the
affected extremity
How is a supine patient fitted for crutches? - ANSWER: measure from the axilla to
the sole and add 2" to the measurement
What is the timeline for assessment? - ANSWER: begins with the nurse's first
encounter with the patient and continues through the patient's stay
How does the nurse obtain assessment data? - ANSWER: health history, physical
examination, review of diagnostic studies
, What is the appropriate size needle for insulin injection? - ANSWER: 25G and 5/8"
long
What is urine called that remains in the bladder after voiding? - ANSWER: residual
urine
normal amount of residual urine - ANSWER: 50 to 100 mL
5 stages of the nursing process - ANSWER: assessment, nursing diagnosis, planning,
implementation, evaluation (ADPIE)
this stage of the nursing process is when the nurse continuously collects data to
identify a patient's actual and potential health needs - ANSWER: assessment
this stage of the nursing process is then the nurse makes a clinical judgement about
individual, family, or community responses to actual or potential health problems or
life processes - ANSWER: nursing diagnosis
this stage of the nursing process is the stage in which the nurse assigns priorities to
nursing diagnoses, defines short-term and long-term goals and expected outcomes,
and establishes the nursing care plan - ANSWER: planning
this stage of the nursing process is the stage in which the nurse puts the nursing care
plan into action, delegates specific nursing interventions to members of the nursing
team, and charts patient responses to nursing interventions - ANSWER:
implementation
this stage of the nursing process is the stage in which the nurse compares objective
and subjective data with the outcome criteria and, if needed, modifies the nursing
care plan - ANSWER: evaluation
What should the nurse do before administering any "as needed" pain medication? -
ANSWER: indicate the location of the pain
this religious belief believes that they shouldn't receive blood components donated
by other people - ANSWER: Jehovah's Witness
to test this, the nurse should ask the patient to cover each eye separately and to
read the eye chart with glasses and without, as appropriate - ANSWER: visual acuity
What must be done when providing oral care for an unconscious patient to minimize
the risk of aspiration? - ANSWER: position the patient on the side
How far away must a patient stand from the chart when assessing distance vision? -
ANSWER: 20 feet
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