2022/2023 Module 6 Exam_ HESI VN , HESI 101 Questions And Answers

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7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 1/109 Question 1 1 / 1 pts Which event would require a ... nurse to complete and file an incident report? A client has a seizure. The nurse determines that a client would benefit from the use of a walker to ambulate. The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion pump is not working. 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. Correct! 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 2/109 Rationale: An incident is any event that is not consistent with the routine operation of a health care unit or routine care of a client. Examples of incidents include client falls, needlestick injuries, a visitor having symptoms of illness, medication administration errors, accidental omission of prescribed therapies, and circumstances leading to injury or a risk for injury. An incident report does not need to be filed if a client has a seizure unless the client sustains injury as a result of the seizure. If the nurse determines that a client would benefit from the use of a walker to ambulate, he or she should take the appropriate action to obtain one. If the nurse notes that the battery of an intravenous infusion pump is not working, he or she should obtain a functioning pump and send the nonfunctioning pump to the appropriate department for repair. Test-Taking Strategy: Use knowledge of the subject, reasons for filing an incident report, to assist you with the process of elimination. Read each option carefully. Recalling that an incident is any event that is not consistent with the routine operation of a health care unit or routine care of a client will direct you to the correct option. Review the reasons for filing an incident report if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 2 1 / 1 pts A nurse, charting the administration of medications to an assigned client at 9 p.m., notes that atenolol (Tenormin) was prescribed to be administered at 9 a.m. instead of 9 p.m. The nurse checks the client’s vital signs, completes an incident report, and calls the health care provider to report the error. The health care provider tells the nurse that an incident report is not needed but instructs her to monitor the client during the night for hypotension. What action should the nurse take? 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 3/109 Notifying the nursing supervisor Tearing up and discarding the incident report Telling the health care provider that the error warrants the completion of an incident report Correct! Telling the nursing supervisor that the health care provider did not want an incident report completed and filed Rationale: Incident reports are an important part of a health care agency’s quality improvement program. An incident is any event that is not consistent with the routine operation of a health care unit or routine care of a client. An example of an incident is administering a medication at a time at which it is not prescribed to be given. Whenever an incident occurs, an incident report is completed and filed in accordance with agency guidelines. The nursing supervisor would be notified of the incident; however, on the basis of the data in the question, the nurse should tell the health care provider that the error warrants completion and follow-through with an incident report. Therefore, the other options are incorrect. Test-Taking Strategy: Focus on the subject of the question, the health care provider’s telling the nurse that an incident report is not needed. Eliminate the comparable or alike options that involve notifying the nursing supervisor. To select from the remaining options, recall the purpose of an incident report to select the correct option. Review the procedures involved in completing and filing incident reports if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 3 1 / 1 pts 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 4/109 Contact precautions are initiated for a client with methicillinresistant Staphylococcus aureus (MRSA) infection. The nurse, providing instructions to a nursing assistant about caring for the client, tells the assistant to take which action? To transfer the client to a semiprivate room That gloves only are needed to care for the client To wear gloves and a gown when changing the client’s bed linen Correct! To wear a gown when caring for the client and remove the gown immediately after leaving the client s room Rationale: Contact precautions require the use of gloves, gown, and goggles if direct client contact is anticipated. The client should be placed in a private room or, if a private room is not available, in a semiprivate room with another client who has active infection with the same microorganism but no other infection. The nursing assistant would remove the protective gear before leaving the client’s room. Test-Taking Strategy: Use the process of elimination. Eliminate the option that includes the closed-ended word “only.” Next eliminate the option that involves removal of the gown after leaving the client’s room. To select from the remaining options, read each carefully and visualize the procedure instituted for contact precautions, which will direct you to the correct option. If you had difficulty with this question, review contact precautions. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management Question 4 1 / 1 pts 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 5/109 The mother of a 3-year-old calls a neighbor who is a nurse and reports that her child just drank some window cleaner that had been stored in a cabinet. The nurse should instruct the mother to immediately take which action? Correct! Call a poison control center. Administer an excessive amount of fluids to induce vomiting. Call an ambulance to bring the child to the emergency department. Leave a message at the health care provider answering service about the incident. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 6/109 Rationale: When a poisoning occurs, a poison center should be called immediately. Vomiting should not be induced if the victim is unconscious or if the substance ingested was a strong corrosive or petroleum product. Also, vomiting should not be induced unless a health care provider has given specific instructions to induce vomiting. Neither calling an ambulance nor calling the health care provider’s answering service is the immediate action, because either would delay treatment. Additionally, the health care provider would immediately make a referral to the poison control center. The poison control center may advise the mother to bring the child to the emergency department; if this is the case, the mother should then call an ambulance. Test-Taking Strategy: Note the strategic word “immediately” in the query of the question. First, recalling that vomiting should not be induced without appropriate advice to do so will help you eliminate the option that involves inducing vomiting. Next eliminate the comparable or alike options that will delay treatment (i.e., calling an ambulance and leaving a message with the answering service). Review immediate poison control measures if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Question 5 1 / 1 pts A hurricane is forecast to make landfall in 48 hours, and the staff of the emergency department of an area hospital is advised to prepare for casualties. Which action should the nurse who receives the telephone call regarding this warning take first? Correct! Activating the agency disaster plan Supplying the triage rooms with additional equipment 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 7/109 Increasing the number of nursing staff for the day on which the hurricane is expected Calling the hospital maintenance department to secure the building against the storm Rationale: In an external disaster, many people may be brought to the emergency department for treatment. Although increasing the nursing staff and supplying the triage rooms with additional equipment may be steps in preparing for casualties, the initial action by the nurse manager must be activation of the disaster plan. Calling the hospital maintenance department to secure the building from the storm is not a responsibility that falls within the scope of nursing management. Test-Taking Strategy: Note the strategic word “first” in the query of the question. Use the process of elimination in determining the priority action. Note that the correct option is the umbrella option. Also remember that other necessary activities will be initiated once the agency disaster plan has been activated. Review procedures related to management in times of disaster if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Disasters Question 6 1 / 1 pts A home health nurse has instructed a client about safety measures during the use of an oxygen concentrator in the home. Which statements by the client indicate to the nurse that the client has understood the directions? Select all that apply. Correct! “I need to follow the oxygen prescription exactly.” 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 8/109 “I can use my electric razor while I’m using oxygen.” “I have to keep the oxygen concentrator out of direct sunlight.” Correct! “I need to keep the oxygen concentrator as close to the wall as possible or put it in a corner.” “I have to tell everyone that they can’t smoke or have an open flame within 10 feet of the oxygen concentrator.” Correct! Rationale: The client should follow the oxygen prescription exactly. The use of electric razors or other equipment that could emit sparks should be avoided while oxygen is in use, because fire and injury to the client could result. The oxygen concentrator is kept out of direct sunlight and slightly away from walls and corners to permit adequate air flow. The client should not allow smoking or any type of flame within 10 feet of the oxygen source. Other measures include having telephone numbers for the health care provider, nurse, and oxygen vendor available and teaching the client signs and symptoms requiring emergency care. Test-Taking Strategy: Recall knowledge of the subject, oxygen safety measures, to assist you with eliminating options. Recall that one hazard associated with oxygen is ignition, which could result from heat in the form of flames or sparks. Evaluating the question from this perspective, eliminate the options that are unsafe. Review oxygen safety measures if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Safety Question 7 1 / 1 pts 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 9/109 A nurse is providing instructions to a nursing student who will be caring for a client in hand restraints. The nurse instructs the nursing student to release the restraints to permit muscle exercise how frequently? Correct! Every 2 hours Every 3 hours Every 4 hours Every 30 minutes Rationale: The nurse should assess the restraints and the client’s circulatory status and skin integrity every 30 minutes. Restraints must be released at least every 2 hours to permit muscle exercise and promote circulation. Agency guidelines regarding the use of restraints should always be followed. Test-Taking Strategy: Knowledge regarding the subject, the use of restraints, is necessary to answer this question. Noting the strategic words “release the restraints” will help direct you to the correct option. Review nursing responsibilities regarding the use of restraints if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Question 8 1 / 1 pts 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, which is the most appropriate initial action? 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 10/109 Implementing a child safety program Planning a focused child safety program Performing an analysis of health problems related to child safety Determining the appropriateness of the planned health activity Correct! Rationale: In this situation, the best initial action would be to determine the appropriateness of the planned health activities. This would be followed by analysis, planning, and implementation. Test-Taking Strategy: Use the steps of the nursing process to answer the question. Note that the correct option involves the process of data collection, the first step of the nursing process. Review the procedure for planning health activities to provide safety if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Question 9 1 / 1 pts The nurse administers a dose of ramipril 2.5 mg to a client at 9 a.m. While documenting administration of the medication, the nurse discovers that 1.25 mg, not 2.5 mg, was the prescribed dose. The nurse assesses the client, completes an incident report, and notifies the health care provider and nursing supervisor of the error. What statement does the nurse add to the client’s record? An incident report was completed and filed. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 11/109 Correct! Ramipril (Altace) 2.5 mg was administered at 9 a.m. Twice the amount of the prescribed ramipril was administered at 9 a.m. Client’s blood pressure was 128/82 mm Hg after the administration of the incorrect dose of ramipril. Rationale: After an incident, the nurse would document a concise and objective description of what occurred and any follow-up actions taken in the client’s record. The nurse would not document in the client’s record that an incident report was completed. Nor would the nurse document that twice the prescribed dose was given or that an incorrect dose was given. Test-Taking Strategy: Focus on the data in the question. Recall that notes made in a client’s record must be objective. Eliminate the comparable or alike options that indicate that an incorrect dose of medication was administered. Next note that the correct option clearly and accurately describes the incident in an objective manner. Review documentation of a medication error or other incident if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Ethical/Legal Question 10 1 / 1 pts A home health nurse has been called to the home of an older postoperative cardiovascular client by the client’s son. The son tells the nurse, “We’re using a hospital bed here at home, but my mother has fallen out of bed three times.” Which observation by the nurse reflects an increased risk of this client’s falling out of bed? 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 12/109 The client’s bed is in a low position. The client is oriented to person, place, and time. The caregiver uses the overbed table for feedings. The caregiver leaves both siderails down while the client is in bed. Correct! Rationale: Leaving the siderails of older client’s bed down may increase the client’s risk of falling. The aging process also increases this client’s potential for falls; therefore, evaluating the safety of the environment is a necessity. Keeping the client’s bed in a low position, orientating the client to the environment, and using the overbed table for feedings are all ways to help ensure the client’s safety. Test-Taking Strategy: Use the process of elimination, focusing on the subject, an observation of an unsafe practice. Noting that the question indicates that the bed is in the low position and that the client is oriented will assist you in eliminating these options. To select from the remaining options, choose the one that identifies an unsafe practice. Review the causes of falls in an older client if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Data Collection Content Area: Safety Ques 1 / 1 pts tion 11 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. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 13/109 Correct! Skin Correct! Lungs Immune Urinary Lymphatic Correct! Gastrointestinal Rationale: Anthrax, caused by Bacillus anthracis, can be contracted through the gastrointestinal system, abrasions in the skin, or inhalation. It is not contracted through the immune system, urinary tract, or lymphatic system. Test-Taking Strategy: Specific knowledge of the subject, the routes of infection with B. anthracis, is needed to answer this question. Remember that anthrax can be contracted through the gastrointestinal system, skin, or lungs. Review content on anthrax and its modes of transmission if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Biological/chemical warfare Question 12 1 / 1 pts A nurse is removing a partially empty chemotherapy infusion bag that was used to administer to a client with a diagnosis of Hodgkin disease. Which precaution should the nurse take while working with this intravenous (IV) infusion? Wearing gloves and a mask 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 14/109 Wearing gloves and a gown Correct! Wearing gloves, a mask, and eye protection Wearing gloves, a mask, and a head covering Rationale: When handling chemotherapeutic agents, the nurse should wear disposable latex gloves, a mask that covers the nose and mouth, and eye protection, especially if a biological hood is not available. Wearing gloves and a mask or gloves and a gown will not provide adequate protection. A head covering is not necessary. Test-Taking Strategy: Knowledge regarding the subject, precautions for handling chemotherapeutic agents, is necessary to answer this question. Think about the effects and cytotoxic nature of chemotherapy to answer the question. Select the option that will provide the greatest degree of protection to the nurse handling chemotherapeutic agents. If you had difficulty with this question, review the precautions for handling a chemotherapy infusion. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Question 13 1 / 1 pts A nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the IV tubing port to the solution bag, the tubing drops, hitting the top of the medication cart. Which action should the nurse take to maintain asepsis? Correct! Obtaining new IV tubing Obtaining a new IV solution bag 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 15/109 Scrubbing the tubing port with an alcohol swab Wiping the tubing port with povidone-iodine solution (Betadine) Rationale: If IV tubing becomes contaminated as a result of coming into contact with some nonsterile object, the nurse should obtain new IV tubing. Contaminated tubing could cause systemic infection in the client. The IV solution bag has not been contaminated and does not need replacement. Wiping the tubing port with Betadine or scrubbing it with alcohol is insufficient and would be contraindicated regardless, because the tubing will be attached directly to a catheter in the client’s vein. Test-Taking Strategy: Visualize the situation as you read the question. Use your knowledge of the subject, basic infection control measures and IV therapy, to answer this question. Also, focus on the data in the question and note that the IV tubing has become contaminated. Review aseptic technique if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control Ques 0 / 1 pts tion 14 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 infection control precautions to be taken at home? You Answered Staying secluded in the bedroom Wearing an oxygen mask at all times 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 16/109 Keeping the house closed up to minimize the spread of disease Disposing of contaminated tissues in a container with a leakproof bag Correct Answer Rationale: The client under infection control precautions at home does not need to remain secluded; the client would not be at home if he or she were infectious. However, proper respiratory precautions are necessary. The house should be properly ventilated, and the windows should be opened as much as possible. Wearing an oxygen mask at all times is not a respiratory precaution, and there is no information in the question to indicate that oxygen is necessary. Contaminated tissues should be discarded in container with a leak-proof bag and then placed in an outdoor trash bin. Tissues should not be left lying around. Test-Taking Strategy: Use the process of elimination. Focus on the client’s diagnosis and the subject, infection control precautions at home. Recalling the mode of transmission and home care measures for TB will direct you to the correct option. Also note the words “secluded,” “all times,” and “closed up” in the incorrect options. If you had difficulty answering this question, review the precautions that should be taken by the client with TB who has been discharged home. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Infection Control Question 15 1 / 1 pts A home health nurse teaches a client about home modifications to reduce the risk of falls. Which statements by the client indicate a need for further teaching? Select all that apply. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 17/109 “I need to use nightlights.” Correct! “I need to remove my wall-to-wall carpeting.” “I need to get handrails put up in the bathroom.” “I need to use the staircase handrails when I go up the stairs.” “I should walk barefoot as much as possible so that I’ll know about any wet spots on the floor.” Correct! Rationale: Home modifications to reduce the risk of falls include ensuring ample lighting, removing scatter rugs, placing handrails in bathrooms, and using handrails on all staircases. The client should wear flat rubber-soled shoes to prevent slips and falls. Walking barefoot will not reduce the risk of injury; in fact, it could actually increase the risk of foot injury and of slipping and falling. Removal of wallto-wall carpeting is not necessary. Test-Taking Strategy: Note the strategic words “need for further teaching.” These words indicate a negative event query and the need to select the incorrect options. Answer this question by eliminating the options that involve providing physical support for the client and that you know are needed in this situation (e.g., nightlights, handrails). Review home care measures to ensure safety and prevent falls if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Ques 1 / 1 pts tion 16 A nurse caring for a client who is under airborne precautions notes that the client is scheduled for a nuclear scan. Which action on the part of the nurse is appropriate? 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 18/109 Planning to have the nuclear scan performed at the bedside Asking the technicians in the nuclear scan department to wear masks Placing a HEPA mask on the client for transport and for contact with other individuals Correct! Calling the nuclear medicine department and telling the technician that the test will have to be delayed until airborne precautions have been discontinued Rationale: If the client is under airborne precautions, client movement and transport should be limited as much as possible. If transport or movement is necessary, the nurse can minimize the dispersal of droplet nuclei from the client by placing a HEPA mask on the client. Having the scan performed at the bedside is not feasible. Asking the technicians in the nuclear medicine department to wear masks would not prevent the dispersal of airborne nuclei from the client. The health care provider is the individual who would prescribe the cancellation or delay of a diagnostic test. Additionally, delaying the test until airborne precautions have been discontinued is not within the role of the nurse. Test-Taking Strategy: Use the process of elimination and focus on the subject of the question, airborne precautions. Knowing that a nurse should not delay a prescribed test will help you eliminate this option. Eliminate the option of having the scan at the bedside because this action is unreasonable. To select from the remaining options, recall the route and mode of transmission of an airborne infection. This should direct you to the correct option. Review airborne precautions if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 19/109 Question 17 1 / 1 pts A nurse employed in a health care provider’s office hears a client in the waiting room call out, “Help! Fire!” The nurse rushes to the waiting room and finds that the wastebasket is on fire. The nurse immediately takes which action? Confines the fire Extinguishes the fire Activates the fire alarm Correct! Removes the clients from the waiting room Rationale: The immediate priority in the event of a fire is removing any clients in immediate danger. The next step is activating the fire alarm. The nurse would then confine the fire by closing all of the doors and, finally, extinguish the fire. Test-Taking Strategy: Use knowledge of the subject, fire safety, to assist you with this question. Remember the mnemonic RACE to prioritize actions in the event of a fire: Rescue clients in immediate danger, sound the alarm, confine the fire by closing all doors, and extinguish. If you had difficulty with this question, review the principles of fire safety. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Question 18 1 / 1 pts 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 20/109 A nurse enters the laundry room to empty a bag of dirty linen and discovers a fire in a laundry basket. What action should the nurse take first? Confining the fire Extinguishing the fire Correct! Activating the fire alarm Running for the fire extinguisher Rationale: The immediate priority in the event of a fire is rescuing the clients in immediate danger. In this situation, no clients are in immediate danger. The next step is to activate the fire alarm. The nurse then confines the fire by closing all doors and, finally, extinguishes the fire. Test-Taking Strategy: Use knowledge of the subject, fire safety, to assist you with this question. Use the mnemonic RACE to remember priorities in the event of a fire: rescueclients in immediate danger, sound the alarm, confine the fire by closing all doors, and extinguish. If you had difficulty with this question, review the principles of fire safety. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Question 19 1 / 1 pts The safety department is providing a yearly educational session on fire safety and the use of fire extinguishers. A nurse is asked to demonstrate the use of a fire extinguisher after the session. The nurse demonstrates appropriate use of the fire extinguisher by first taking which action? 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 21/109 Aiming at the base of the fire Correct! Pulling the pin on the fire extinguisher Squeezing the handle of the extinguisher Sweeping from the top to the bottom of the fire with the extinguisher Rationale: To use a fire extinguisher, pull the pin first. Next, aim the extinguisher at the base of the fire. Squeeze the handle of the extinguisher, then extinguish the fire by sweeping from side to side to coat the area evenly. Test-Taking Strategy: Use knowledge of the subject, fire safety, to assist you with this question. Use the mnemonic PASS to remember the steps in the use of a fire extinguisher: Pull the pin, aim at the base of the fire, squeeze the handle, and sweep from side to side to coat the area evenly. If you had difficulty with this question, review the appropriate use of a fire extinguisher. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Ques 1 / 1 pts tion 20 A nurse provides instruction to a new nurse employee regarding the application of a restraint to a client. The nurse watches as the nurse employee applies the restraint. What observation tells the nurse that the nurse employee is using correct procedure? The employee applies a tie knot in the restraint strap. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 22/109 The employee attaches the restraint straps securely to the siderails. The employee applies the restraint so that the strap does not tighten when force is applied against it. Correct! The employee secures the restraint in such a way that it is impossible to slip a finger between the restraint and the client’s skin. Rationale: A half-bow or safety knot should be used to apply a restraint, because it does not tighten when force is applied against it and because it allows quick, easy removal of the restraint in the event of an emergency. The restraint strap is secured to the bed frame, never to the side rails, to help prevent accidental injury in the event that the siderail is released. A restraint should be secured in such a way that one or two fingers can be easily slipped between the restraint and the client’s skin. Test-Taking Strategy: Note the strategic words “correct procedure” in the query. This indicates that you are looking for an option that involves an accurate measure of how a restraint is applied. Use the process of elimination and your knowledge of safety measures and the use of restraints to answer the question. Noting the words “tie knot,” “siderails,” and “impossible to slip” will assist you in eliminating these options. Review guidelines for the application of restraints if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management Question 21 1 / 1 pts 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 23/109 A nurse is instructing a group of nursing assistants in the principles of body mechanics. Which observations tell the nurse that a nursing assistant is using the principles appropriately? Select all that apply. The assistant leans forward when turning a client in bed. The assistant positions a box that is to be lifted between his knees. Correct! The assistant turns his back to change position while moving a client. The assistant keeps the object to be moved as close to his body as possible. Correct! The assistant helps a client requiring total care into a chair without additional assistance. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 24/109 Rationale: When moving an object, the nursing assistant should position the object between his knees. The assistant should keep the client or object to be moved as close to his body as possible. When turning a client, the assistant should keep his back straight and take small steps with the feet. The assistant should turn his feet, rather than twisting his back, if a change in direction is necessary when carrying an object or a client. The assistant should seek out assistance when transferring a client who requires total care. Test-Taking Strategy: Use the process of elimination and your knowledge of the subject, body mechanics, to answer the question. Visualize each of the items in the options to determine which actions could result in injury. Review the principles of body mechanics if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management Question 22 1 / 1 pts A home care nurse visits a client during the winter, who lives in a small apartment, to perform a dressing change . During the lengthy procedure, the client asks the nurse whether it is safe to use a space heater. What is the appropriate response by the nurse? “A space heater should never be used in an apartment.” “A space heater can be used as long as it is kept at a low setting at all times.” “A space heater can be used as long as it is kept in the bedroom at night in case a fire occurs.” 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 25/109 “A space heater can be used as long as it’s placed at least 3 feet from anything that may ignite.” Correct! Rationale: Space heaters must be used appropriately because of the risk of fire. A space heater should be placed at least 3 feet from anything that may ignite. A space heater may be used in an apartment if there is ample space and safety precautions are followed. A low setting does not reduce the risk of fire. Placing a heater in a bedroom does not guarantee that it will be 3 feet from anything that may ignite. Test-Taking Strategy: Use the process of elimination, keeping in mind the subject, fire safety. Eliminate the options that include the closed-ended words “never” and “all.” To select from the remaining options, note that the correct option is the only one that specifically defines a safety measure involving the use of a space heater. Review fire safety measures in the home if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Ques 1 / 1 pts tion 23 A nurse is preparing to initiate a continuous tube feeding, using a tube-feeding pump. On bringing the pump to the bedside and preparing to plug in the pump, the nurse discovers that there is no available plug in the wall socket. What should the nurse do? Plug in the pump cord into an available plug above the sink. Ask the health care provider to change the prescription to intermittent feedings. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 26/109 Determine the need for the appliances now plugged into the needed wall socket. Correct! Use a regular extension cord to allow the use of more than one electrical appliance. Rationale: It is most appropriate for the nurse to assess the situation and determine the need for the appliances already plugged into the needed wall socket. The use of electrical appliances near a sink presents a hazard. It is not appropriate (and is premature) to ask the health care provider to change the prescription, because the prescription is based on the client’s needs. A regular extension cord should not be used because it poses a risk of fire. Test-Taking Strategy: Use process of elimination and the steps of the nursing process to answer the question. The only option that addresses collecting data is the one that involves determining the need for the appliances currently plugged into the needed wall socket. Review electrical safety procedures if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Question 24 1 / 1 pts View video. A nurse, preparing a sterile field on which to perform a dressing change, places the sterile drape on the overbed table. Which actions on the part of the nurse indicate correct understanding of the principles of aseptic technique? Select all that apply. Holding the pair of sterile forceps below waist level area 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 27/109 Correct! Positioning the sterile field so that it remains in full view Reaching across the sterile field to pick up a sterile gauze 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 Correct! Pouring sterile wound cleansing solution into a sterile cup before donning sterile gloves Correct! Rationale: View video. The principles of surgical asepsis must be followed in the preparation of a sterile field. Among these principles are the following: a sterile object remains sterile only when touched by other sterile objects; only sterile objects may be placed on a sterile field; a sterile object or field out of the range of vision or an object held below the nurse’s waist is to be considered contaminated; a sterile object or field becomes contaminated with prolonged exposure to air; when a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by way of capillary action; fluid flows in the direction of gravity; and a 1-inch edge of a sterile field or container is to be considered contaminated. Test-Taking Strategy: Focus on the subject, use of the principles of aseptic technique. Reading each option carefully and recalling the principles of aseptic technique will direct you to the correct options. Review aseptic technique and the procedure for preparing a sterile field if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 28/109 Question 25 1 / 1 pts A licensed practical nurse (LPN) tells the registered nurse (RN) that she administered acetaminophen (Tylenol) to a client by way of the rectal route rather than the prescribed oral route because the client was extremely nauseated. The RN most appropriately takes which action? Correct! Asks the LPN to complete and file an incident report Asks the LPN to check the client in 30 minutes to see whether the nausea has subsided Tells the LPN that she made a sound judgment in administering the medication by way of the rectal route Instructs the LPN to write “pr” (per rectum) on the medication record next to the time at which the medication was administered 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 29/109 Rationale: If a medication is prescribed to be administered by way of the oral route, the nurse may not use an alternate route to administer the medication unless the change is prescribed by the health care provider. The nurse would ask the LPN to complete and file an incident report because the LPN, legally speaking, made a medication error. Telling the LPN that she made a sound judgment in administering the medication by way of the rectal route is incorrect. Although the client must be reassessed and the LPN would document administration of the medication by way of the rectal route in the client’s record, the most appropriate option given is having the LPN complete and file an incident report. Test-Taking Strategy: Use the process of elimination, and note the strategic words “most appropriately.” Focusing on the data in the question indicates that the LPN made a medication error. This will direct you to the correct option. Review the appropriate actions in the event of a medication error if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Ethical/Legal Question 26 1 / 1 pts A nurse receives a telephone call from the admissions office and is told that a client scheduled for an internal radiation implant will be admitted to the nursing unit. Which precaution does the nurse include in the client’s plan of care? Correct! Wearing gloves when emptying the client’s bedpan Allowing the client to ambulate in the hall only once a day Placing the client in a semiprivate room at the end of a hallway 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 30/109 Placing used linen in double bags and sending a bag to the laundry room every evening Rationale: A primary goal of care for the client with an internal radiation implant is to prevent exposure of others to radiation. Therefore, a client with an internal radiation implant is required to remain in a private room to prevent accidental exposure of other clients, staff, and visitors to radiation. For this reason, a private room with a private bath is essential. All client linens should be kept in the client’s room until the implant is removed. Wearing gloves when emptying the client’s bedpan is the only appropriate intervention, of those provided, for a client with an internal radiation implant. Test-Taking Strategy: Use the process of elimination. Eliminate the option that includes the closed-ended word “only.” Also eliminate the option involving the use of a semiprivate room. To select from the remaining options, use your knowledge of standard precautions and precautions for a client with an internal radiation implant. This will direct you to the correct option. Review radiation safety principles if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Safety Ques 1 / 1 pts tion 27 A nursing instructor is observing a nursing student who is practicing the use of standard precautions in the nursing laboratory. Which observation by the instructor indicates a need for further teaching? The nursing student changes gloves between tasks and procedures. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 31/109 The nursing student washes hands before making contact with the client. The nursing student wears a gown to change the bed of an incontinent client. The nursing student washes her hands before glove removal after emptying a Foley bag. Correct! Rationale: Standard precautions require that gloves be removed promptly after use and before the wearer touches noncontaminated surfaces or other clients. Gloves are not washed before removal because splashing of contaminated material may result. Changing gloves between tasks and procedures, washing the hands before making contact with the client, and wearing a gown to change the bed of an incontinent client reflect correct understanding of the principles of standard precautions. Test-Taking Strategy: Note the strategic words “need for further teaching.” These words indicate a negative event query and the need to select the incorrect action. Use the process of elimination, visualizing each of the procedures described in the options. Thinking about the principles of standard precautions will direct you to the correct option. Review the principles associated with standard precautions if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Infection Control Question 28 0.67 / 1 pts A health care provider writes a prescription for the application of a heating pad to a client’s back. Which actions should the nurse take when implementing this prescription? Select all that apply. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 32/109 Placing the heating pad under the client Adjusting the heating pad to the high setting Correct! Frequently monitoring the client’s skin for signs of burns Reviewing the client’s medical history and risk factors for burns Correct! Examining the heating pad periodically for proper electrical function Correct Answer Question 29 1 / 1 pts A home care nurse is instructing a client in the use of ice packs to treat an eye injury. The nurse instructs the client to take which action? Place the ice pack directly on the eye. Avoid the use of commercially prepared ice bags. Keep the ice pack on the eye continuously for 24 hours. Wrap a plastic bag filled with ice in a pillowcase and place it on the eye. Correct! 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 33/109 Rationale: An ice pack placed directly against the skin or left in place for an extended period carries a risk of tissue damage similar to that of a hot water bottle. To help prevent tissue damage resulting from excessive cold exposure, the ice pack should be removed in most cases after 30 minutes; after a short time it may be reapplied. An ice pack should never be placed directly against the skin; instead, it should be covered with a pillowcase or towel. Commercially prepared ice bags are appropriate for use as ice packs. Test-Taking Strategy: Use knowledge of the subject, safety measures for the use of ice packs, to assist you with the process of elimination to answer the question. Eliminate the options that include the words “directly” and “continuously.” From the remaining options, recall that the use of commercially prepared ice bags for the purpose described in the question is acceptable. Review safety measures for the use of ice packs if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Question 30 1 / 1 pts A fever develops in a client who has been hospitalized for 2 months and is receiving parenteral nutrition by way of a central venous line, and central venous line–related sepsis is diagnosed. The nurse interprets this finding as meaning that this is which type of infection? An iatrogenic infection A result of bacterial colonization A community-acquired infection 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 34/109 Correct! A health care–associated infection Rationale: Infections that occur during hospitalization, or are a result of hospitalization, are referred to as health care–associated infections, hospital-acquired infections, or nosocomial infections. Colonization is defined as a condition in which microorganisms are present in body tissues; there is no damage to the tissues, and no local signs or symptoms of infection are evident. Iatrogenic infections are infections that involve the client’s normal flora. A community-acquired infection is an infection that the person is admitted with or is incubating on admission to the hospital. Test-Taking Strategy: Focus on the data in the question. Noting that the fever and sepsis developed while the client was hospitalized will direct you to the correct option. Review the various types of infection and the definition of colonization if you had difficulty answering this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Assessment Content Area: Infection Control Question 31 1 / 1 pts A nurse educator is providing inservice sessions to the nursing staff regarding employee safety and the prevention of occupationally acquired HIV infection. Which 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 Correct! The use of shielded needles Correct! The use of recessed needles 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 35/109 Correct! The use of needleless devices Correct! Disposal of needles in special puncture-resistant containers Rationale: Although strict adherence to universal or standard precautions can reduce significantly the incidence of exposure to blood or body fluid, latex gloves cannot prevent a needlestick. The use of recessed needles, needleless devices, shielded needles, and puncture-resistant containers for the disposal of needles are all of significant benefit in the prevention of accidental needlesticks. Test-Taking Strategy: Focus on the subject, preventing accidental needlesticks, to answer the question. Visualize each of the options and how the action might or might not prevent a needlestick. This will help you answer correctly. Review standard precautions if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Infection Control Question 32 1 / 1 pts A nurse is preparing to clean up a blood spill on the client’s bedside table that occurred when a blood tube containing a specimen from the client broke. What steps should the nurse take to clean up the blood spill? Select all that apply. Correct! Using tongs to collect any broken glass Correct! Wearing gloves for the cleanup procedure Placing the pieces of broken glass in a plastic bag 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 36/109 Blotting up the spill with a face cloth or cloth towel Disinfecting the area of the blood spill with a dilute bleach solution Correct! Rationale: The nurse should blot the spill with an absorbent disposable material such as disposable paper towels or terry wipes, not a face cloth or towel. Tongs are used to pick up any broken glass, and gloves are worn for the procedure. The broken glass is disposed of in a puncture-resistant container. The area is disinfected with a dilute bleach solution or other agency-accepted product. Test-Taking Strategy: Read each option carefully. Use knowledge of the subject, cleaning up a blood spill, to assist you with this question. Visualizing the actions identified in each option and recalling the principles associated with standard precautions will direct you to the correct options. Review the procedure for cleaning up blood spills if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Ques 1 / 1 pts tion 33 The emergency department nurse who is on duty is informed by the charge nurse that an airplane crash has occurred and numerous casualties will be arriving at the ED. What should the initial response by the nurse be? Correct! “Has the disaster plan been activated?” “Call as many nursing staff as you can to come in to work.” “Make sure all of the rooms are well stocked with supplies.” 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 37/109 “Be sure that the nursing staff finds as many stretchers as they can.” Rationale: In an external disaster, many people will be brought to the ED for treatment. Although ensuring that rooms are well stocked with supplies, calling nursing staff to come to work, and finding stretchers are components of preparing for the casualties, the initial nursing action must be activation of the disaster plan. Therefore the initial response by the nurse should be “Has the disaster plan been activated?” Test-Taking Strategy: Note the strategic words “initial response” in the query. Focus on the data in the question and note that the correct option is the umbrella response. Review procedures related to management of a disaster if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Disasters Ques 1 / 1 pts tion 34 A community health nurse is providing an educational session on childhood poisoning at a local school. The nurse tells the group that when an accidental poisoning occurs the first action is to take which action? Induce vomiting. Call an ambulance. Correct! Call the poison control center. Bring the child to the emergency department (ED). 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 38/109 Rationale: When a poisoning occurs, a poison control center should be contacted immediately and any directions given regarding treatment followed. The poison control center will provide directions regarding the inducement of vomiting. However, vomiting should not be induced if the victim is unconscious or if the substance ingested is a strong corrosive or petroleum product. The poison control center may advise the mother to bring the child to the ED; if this is the case, the mother should call an ambulance. Neither bringing the child to the ED nor calling an ambulance would be the immediate actions because either tactic would delay treatment. Test-Taking Strategy: Note the strategic word “first” in the query of the question. Eliminate the comparable or alike options that involve a delay in starting treatment (calling an ambulance and bringing the victim to the emergency department). Recalling that vomiting should not be induced in certain types of poisoning will help you eliminate this option. Review immediate poison control measures if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Ques 1 / 1 pts tion 35 A client undergoing chemotherapy is found to have an extremely low white blood cell count, and neutropenic precautions, including a low-bacteria diet, are immediately instituted. Which of these food items will the client be allowed to consume? Select all that apply. Fresh apple Raw celery Correct! Italian bread 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 39/109 Tossed salad Correct! Baked chicken Correct! Well-cooked cheeseburger Rationale: An extremely low white blood cell count puts the client at risk for infection, necessitating the implementation of a low-bacteria diet. The client must avoid fresh fruits and vegetables, which may harbor microorganisms that could cause infection, and ensure that meat is thoroughly cooked. Italian bread, baked chicken, and a well-done cheeseburger are all acceptable foods for the client. Test-Taking Strategy: Focus on the subject of the question, a low-bacteria diet. Read each option carefully and think about the foods that harbor bacteria. Recalling that fresh fruits and vegetables are restricted in a lowbacteria diet will help you select the correct items. Review interventions for the client on a low-bacteria diet if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control Question 36 1 / 1 pts Which actions should the nurse take in the event of an accidental poisoning? Select all that apply. Correct! Saving vomitus for laboratory analysis Placing the client in the supine position Correct! Determining the type and amount of substance ingested 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 40/109 Correct! Removing any visible materials from the nose and mouth Inducing vomiting if a household cleaner has been ingested Assessing the client s airway patency, breathing, and circulation Correct! Rationale: In the event of accidental poisoning, the poison center is called before any attempt at interventions is made. Additional interventions in an accidental poisoning include assessing the client’s airway patency, breathing, and circulation; removing any visible materials from the nose and mouth to terminate exposure; determining the type and amount of substance ingested, if possible, to identify an antidote; saving vomitus for laboratory analysis, which may aid further treatment; and positioning the victim with the head to the side to prevent aspiration of vomitus and help keep the airway open. Because of the risk of aspiration, vomiting is never induced in an unconscious client or in a client who is experiencing seizures. Additionally, vomiting is not induced if lye, a household cleaner, a hair-care product, grease, a petroleum product, or furniture polish has been ingested because of the risk of internal burns. Test-Taking Strategy: Focus on the subject, interventions in the event of accidental poisoning. Visualize each of the interventions and how they might be helpful in treating the poisoning. Use of the ABCs (airway, breathing, and circulation) will also help you determine the correct interventions. Remember, too, that caustic substances may cause further injury to the client if vomiting is induced. If you had difficulty with this question, review the interventions for a victim of accidental poisoning. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Ques 1 / 1 pts tion 37 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 41/109 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.f Mask Correct! Gown Correct! Gloves Correct! Face shield Shoe protectors Rationale: Infection caused by MRSA necessitates contact precautions. The care of this client requires the use of gown, gloves, and a face shield. The face shield is worn to protect the face and the mucous membranes of the mouth, nose, and eyes during interventions that could produce splashes of blood, body fluids, secretions, and excretions (e.g., wound irrigation and suctioning). Contact precautions also require the use of gloves and a gown if direct client contact is anticipated. A mask does not provide adequate protection. Shoe protectors are not necessary. Test-Taking Strategy: Focus on the data in the question, and think about the events that might occur during a wound irrigation and suctioning. This will help you determine the necessary items for the care of this client. If you had difficulty with this question, review standard and contact precautions. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 42/109 Question 38 1 / 1 pts A nurse is assisting with disaster relief after a tornado. The nurse’s goal with the overall community is to prevent as much injury and death resulting from the uncontrollable event as possible. Finding safe housing for survivors, providing support to families, organizing counseling sessions, and securing physical care when needed are all examples of which level of prevention? Initial Primary Correct! Tertiary Secondary Rationale: Tertiary prevention involves the reduction of the amount and degree of disability, injury, and damage after a crisis. Primary prevention is aimed at keeping a crisis from ever occurring, and secondary prevention is focused on reducing the intensity and duration of the crisis during the actual crisis. There is no such thing as the initial prevention level. Test-Taking Strategy: Focus on the data in the question and the nurse’s goal. Note that the goals of care involve activities undertaken after the disaster. This will assist you in identifying the correct level of prevention. If you had difficulty with this question, review the levels of prevention. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Disasters Question 39 1 / 1 pts 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 43/109 A nurse in a postanesthesia care unit (PACU) receives a client from the operating room. For what finding should the PACU nurse assess the client first? Correct! Airway patency Active bowel sounds Adequate urine output Orientation to surroundings Rationale: After a client’s transfer from the operating room, the PACU nurse performs an assessment, assessing airway patency first. The client may not have active bowel sounds at this time as a result of the effects of anesthesia. Urine output and orientation to surroundings may also be assessed, but these are not the first priorities. Test-Taking Strategy: Note the strategic word “first.” Use your knowledge of the ABCs—airway, breathing, and circulation—to identify the correct option. Review the initial actions to be taken in the care of a postoperative client if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Question 40 1 / 1 pts 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 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 appropriate? 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 44/109 Asking a family member to sit with the client Asking a nursing assistant to monitor the client Staying with the client and consulting with the nurse manager about the situation Correct! Telling the family that the application of wrist restraints is critical in preventing injury to the client Rationale: The nurse must stay with the client and consult with the nurse manager about the situation. It may be necessary for the nurse manager to call the supervisor to request an additional staff member to care for the client. Because the client has a head injury, the development of increased intracranial pressure (ICP) is a major concern. A nursing assistant is not trained to monitor the client for increased ICP. It is inappropriate to ask a family member to sit with the client. The application of restraints may agitate the client, causing further restlessness and thus increasing ICP. Test-Taking Strategy: Use the process of elimination, noting the strategic word “appropriate.” Focus on the data in the question, noting that the client has sustained a head injury, and remember that the client with a head injury is at risk for increased ICP. Eliminate the comparable or alike options (i.e., asking a family member or the nursing assistant to stay with the client). To select from the remaining options, recall that the application of restraints could agitate the client. Review the guidelines for the use of restraints and nursing responsibilities when a client requires continuous monitoring if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 45/109 Question 41 1 / 1 pts The licensed practical nurse (LPN), who is the unit charge nurse of a long-term care facility, arrives at work to find the entire facility has about an inch of standing water from a leak in the laundry room. Some residents have minor lacerations from slipping in the water. In addition, several nursing assistants and another staff LPN have called in due to illnesses. Several new residents are scheduled to be transferred to the long-term care facility from the hospital today. The nurse should initially manage the situation by taking which action? Telling EMS to take the residents to another facility Closing the facility temporarily to incoming residents Calling the nursing supervisor to discuss activation of the disaster plan T Correct! Demanding that the nurses from the night shift stay until all of the victims have been treated 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 46/109 Rationale: Internal disasters occur within the facility and will affect the facility’s ability to provide care. In this situation, the nurse would initially call the nursing supervisor to discuss the need for additional staffing and activation of the disaster plan. The nurse would not ask EMS to take the victims to another facility or temporarily close the facility to incoming clients; such decisions are made by facility administrators. The nurse should ask, not demand, that nurses from the night shift stay until all of the victims have been treated. Test-Taking Strategy: Use the process of elimination, noting the strategic word “initially” in the query of the question. First eliminate the option containing the word “demanding.” Next eliminate the comparable or alike options that refer to the role of a facility administrator. Review the procedures for management in times of disaster if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Question 42 1 / 1 pts A nurse responds to an external disaster that occurred in a large city when a building collapsed. Numerous victims require treatment. Which victim should the nurse attend to first? A victim who has died of multiple serious injuries A hysterical victim who has sustained a head injury An alert victim who has numerous bruises on the arms and legs A victim with a partial amputation of a leg who is bleeding profusely Correct! 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 47/109 Rationale: The nurse determines which victim will be attended to first on the basis of the severity of injury of each of the victims of the disaster. An injury that threatens life, limb, or vision without immediate attention is categorized as emergent and is the priority (in this case, the victim with a partial amputation who is bleeding profusely). A victim who requires treatment but whose life, limbs, and vision are not threatened if care can be provided within 1 to 2 hours is considered to represent an urgent case and is the second priority (here, the hysterical victim who has sustained a head injury). Local injuries that require evaluation and possibly treatment but for which time is not critical are categorized as nonurgent and represent the third priority (here, the victim with numerous bruises on the arms and legs). Caring for a victim who is already dead is the final priority. Test-Taking Strategy: Note the strategic word “first,” and use your knowledge of the principles of to triage. Note the words “bleeding profusely” in the correct option. Review the principles of triage if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Question 43 1 / 1 pts A nurse giving a client a bed bath drops the towel on the floor. The nurse should take which action? Use a bath blanket as a towel. Borrow a towel from the client’s roommate. Wash her hands, pick up the towel, and shake the towel out. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 48/109 Wash her hands and go to the linen room to obtain another towel. Correct! Rationale: To avoid spreading the client’s microorganisms, the nurse must wash her hands before leaving the client’s room. Therefore the nurse should cover the client and ensure that the client is safe, wash her hands, and go to the linen room to obtain another towel. It is not appropriate to use a bath blanket as a towel. It is never appropriate to borrow other clients’ supplies because this is inconsistent with the principles of infection control. The nurse would never use linen that had been dropped on the floor. Also, shaking linen spreads germs. Test-Taking Strategy: Focus on the data in the question, and note that the nurse has dropped the towel on the floor. Read each option carefully, and use your knowledge of infection control and the principles of bathing a client to direct you to the correct option. Review the principles of infection control if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control Ques 1 / 1 pts tion 44 A nurse is attending an inservice program on disaster preparedness. Which event is described as an example of a natural disaster? Correct! Drought Bus accident Terrorist attack 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 49/109 Toxic waste spill Rationale: A disaster is any human-made or natural event that results in destruction and devastation that cannot be alleviated without assistance (i.e., medical, local, or federal government assistance). A natural disaster usually cannot be prevented, whereas a human-made disaster can be prevented. A drought is the only natural disaster identified in the options. Bus accidents, terrorist attacks, and toxic waste spills are all human-made disasters. Test-Taking Strategy: Focus on the subject, a natural disaster. Recalling that this type of disaster is one that usually cannot be prevented will direct you to the correct option. Review the types of disasters if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Disasters Question 45 0 / 1 pts A licensed practical charge nurse in a long-term care facility tells the nursing staff that the agency’s disaster preparedness plan will be distributed to all employees for review. The nurse states that the plan is an important component of disaster readiness because it primarily has which purpose? Identifies the location of health care supplies You Answered Identifies the types of disasters that may occur Aids determination of how victims will be triaged 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 50/109 Describes a formal plan of action for the coordination of a response Correct Answer Rationale: A disaster preparedness plan is a formal plan of action for coordinating the response of a health care agency’s staff in the event of a disaster in the agency itself or in the surrounding community. Depending on the agency, the disaster preparedness plan may be specific and may include other information such as the location of health care supplies, instructions for the triage of victims, and the types of disasters that may occur. Test-Taking Strategy: Use the process of elimination and note the strategic word “primarily.” Note that the correct option is the umbrella option. Review the description of a disaster preparedness plan if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Disasters Ques 1 / 1 pts tion 46 A nurse is reading an article about the role of the American Red Cross (ARC) in a disaster. Which responsibility does the article ascribe to the ARC? Declaring a disaster Correct! Providing disaster relief Activating disaster medical assistant teams Developing a federal disaster response plan 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 51/109 Rationale: The ARC has been given authority by the federal government to provide disaster relief. This organization works with the government in developing and testing community disaster plans, identifying and training personnel for disaster response, working with businesses and labor organizations to identify resources and people for disaster work, and educating the public about ways to prepare for disasters. Other responsibilities include operating shelters, providing assistance to meet immediate emergency needs, and providing disaster health services. Declaring a disaster, developing a federal disaster response plan, and activating disaster medical assistant teams are responsibilities of the Federal Emergency Management Agency. Test-Taking Strategy: Focus on the subject, the roles and responsibilities of the ARC. Read each option carefully and think about the parties involved in each action in the options; this will direct you to the correct option. Review the roles of the ARC in a disaster if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Disasters Question 47 1 / 1 pts A nurse leading an educational session about terrorism for members of the community is discussing anthrax. Which pieces of information should the nurse provide to the group attending the session? Select all that apply. Anthrax is never fatal. No vaccine to prevent anthrax is available. Anthrax can be transmitted from person to person. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 52/109 Correct! A blood test is available for the detection of anthrax. Correct! One way that anthrax can be contracted is through the skin. Rationale: Anthrax, which is caused by Bacillus anthracis, can be contracted through the digestive system or abrasions in the skin or by way of inhalation. In the lungs, anthrax can cause a buildup of fluid, tissue decay, and death; untreated pulmonary anthrax is fatal. A blood test performed to detect anthrax magnifies DNA from the blood sample and matches it to anthrax DNA. A vaccine exists, but its availability is limited. Anthrax is usually treated with ciprofloxacin, doxycycline, or penicillin. Test-Taking Strategy: Knowledge regarding the subject, the ways of contracting anthrax, is needed to answer this question. Recalling that there are three modes of entry into the body will assist in eliminating the option that indicates that anthrax can be transmitted person to person. Next eliminate the options using the closed ended words “never” and “no.” Review information related to anthrax infection if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Biological/chemical warfare Question 48 1 / 1 pts According 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? Response Recovery 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 53/109 Correct! Mitigation Preparedness Rationale: The mitigation phase consists of actions or measures that can either prevent the occurrence of a disaster or reduce a disaster’s damaging effects. The task of determining the resources available for the care of infants, older clients, the disabled, and people with chronic health problems is addressed in this phase. The preparedness phase involves actions that plan for rescue, evacuation, and care of disaster victims. The response phase involves putting disaster-planning services into action and enumerating the actions needed to save lives and prevent further damage. The recovery phase includes actions taken to return to normal after the disaster. Test-Taking Strategy: Focus on the subject, available resources. Think about the definition of each item in the options. This will help you determine the correct phase. Review the phases of disaster management if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Biological/Chemical Warfare Question 49 1 / 1 pts An older client is extremely anxious after admission, having never been hospitalized before. To help provide a safe environment and minimize the stress of hospitalization on the client, what does the nurse plan to do? Select all that apply. Keep visitors to a minimum Correct! Acknowledge the client’s feelings 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 54/109 Correct! Provide information about hospital routines Put the client in a room far from the nurses’ station Keep the door open and the room lights on at all times Allow the client to have as many choices regarding his care as possible Correct! Rationale: Several general interventions can be used to minimize stress in the hospitalized client. These include acknowledging the client’s feelings, providing information, providing social support, and giving the client control, when possible, over choices related to care. Admitting the client to a room far from the nurses’ station and limiting visitors would both serve to increase the client’s anxiety. Keeping the door open and the room lights on at all times could cause further disruption in the client’s sleep pattern in addition to the disruption created by the hospitalization. Test-Taking Strategy: The strategic words are “safe” and “minimize the stress.” This tells you that the correct option(s) allay(s) the client’s fears and anxiety after sudden placement in a foreign environment. Use your knowledge of the principles of safety and stress reduction to answer the question and review these principles if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Safety Ques 1 / 1 pts tion 50 A nurse is preparing a disaster preparedness checklist, identifying emergency plans and supplies that will be needed in the event of a disaster, for a community group. Which instructions should be included on the list? Select all that apply. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 55/109 Correct! Have a first aid kit available. Have a firearm or other weapon available. Correct! Plan a meeting place for family members. Obtain a 1-day supply of water (1 gallon per person). Correct! Have an adequate supply of prescription medications. Have a battery-operated radio and a flashlight and batteries available. Correct! Rationale: Personal preparedness for a disaster includes planning a meeting place for family members, identifying safe spots in the home for each type of disaster; having a 3-day supply of water (1 gallon per person per day) and a 3-day supply of nonperishable food; and having clothing and blankets, a first aid kit, a battery-operated radio, a flashlight, and batteries available. For safety reasons, the nurse would not recommend that a weapon be kept. Test-Taking Strategy: Focus on the subject, a disaster preparedness checklist. Thinking about necessities in the event of a disaster and about safety will assist you in identifying the items needed. Review the items needed in the event of a disaster if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Disasters Ques 1 / 1 pts tion 51 A triage nurse in an emergency department (ED) is attending to the victims of a train crash. All victims are alert. Which of these 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 56/109 clients does the nurse assign to the emergent category? Select all that apply. Correct! A victim with respiratory distress A victim with a fractured humerus Correct! A victim with partial amputation of the foot A victim with a forehead laceration that is not bleeding A victim with multiple nonbleeding bruises of the arms and legs 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 57/109 Rationale: One rating system commonly used in the ED consists of three tiers—emergent, urgent, and nonurgent —with the categories sometimes identified with color coding or numbers. The emergent classification (a.k.a. red or priority 1) is given to clients with life-threatening injuries (here, the clients with respiratory distress [airway] and partial amputation of the foot [bleeding/circulation]) who require immediate attention and continuous evaluation but have a high chance of survival once their conditions have been stabilized. The urgent (a.k.a. yellow or priority 2) classification is given to clients whose injuries and complications are not life-threatening (here, the client with the fractured humerus), provided that they are treated within 1 to 2 hours; such clients require evaluation every 30 to 60 minutes thereafter. The nonurgent (a.k.a. green or priority 3) classification is given to clients with local injuries (here, the clients with the forehead laceration and bruises of the arms and legs) who do not have immediate complications and can wait several hours for medical treatment; these clients require evaluation every 1 to 2 hours thereafter. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation—which will easily direct you to the correct options. Respiratory distress involves the airway, and the victim with amputation is at risk for bleeding (i.e., circulation). Review the triage system and priorities of care if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Disasters Question 52 1 / 1 pts A nurse is questioning a client about hazards in the home environment. Which items in the home are an indication that the client requires instruction about safety? Select all that apply. Correct! Untacked rugs on the stairs 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 58/109 Correct! Small rugs in the living room Carpet on stairs secured with tacks Clothes hamper at the end of the hallway Cereal boxes, canned foods, and infrequently used cooking utensils stored on top of the refrigerator Correct! Rationale: Area rugs and runners should not be used on or near stairs. Injuries in the home are frequently the result of loose objects, including small rugs on the stairs or floor, wet spots on the floor, or clutter on bedside tables, closet shelves, the top of the refrigerator, and bookshelves. Care should also be taken to ensure that end tables are secure and have stable straight legs. Nonessential items should be placed in drawers to eliminate clutter. If the stairs must be carpeted, carpeting should be secured with the use of tacks. Test-Taking Strategy: Note the strategic words “requires instruction.” These words indicate a negative event query and the need to identify safety hazards in the environment. Reading each option carefully will assist you in answering correctly. Review safety hazards in the home if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Ques 1 / 1 pts tion 53 A home health nurse is assisting with data collection of a client’s skin. The nurse, noting multiple threadlike lines, both straight and wavy, beneath the skin, recognizes the presence of scabies. Which precautions should the nurse institute before completing the assessment of the client? 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 59/109 Putting on a pair of gloves Donning a mask and gloves Correct! Putting on a gown and gloves Avoiding sitting on the client’s furniture Rationale: Scabies is usually transmitted from person to person by way of direct skin contact. The Centers for Disease Control and Prevention recommends the wearing of gowns and gloves for close contact with a person infested with scabies. Masks are not necessary. Transmission by way of clothing and other inanimate objects is uncommon. Everyone with whom the client has had contact should be treated for scabies at the same time. Test-Taking Strategy: Consider the mode of transmission of scabies and use knowledge of the subject to help you with the process of elimination in answering the question. Knowing that scabies is transmitted by way of direct skin contact will assist you in answering correctly. If you had difficulty with this question, review standard precautions and the transmission of scabies. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control Question 54 1 / 1 pts An industrial nurse at a large factory provides information to the employees in the mailroom and shipping department about the signs of skin (cutaneous) anthrax. For which early sign of cutaneous anthrax does the nurse tell the employees to check their skin? 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 60/109 An open ulcer Correct! An itchy bump A weeping blister A black skin area of skin Rationale: Skin anthrax starts with an itchy bump (papule) that looks like a mosquito bite. It progresses to a small fluid-filled sac that becomes a painless ulcer with an area of dead black tissue in the middle. (Toxins from the anthrax spores destroy the surrounding tissue.) Test-Taking Strategy: Focus on the data in the question. Noting the strategic word “early” will direct you to the correct option. Review the early signs of cutaneous anthrax if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Biological/Chemical Warfare Question 55 0 / 1 pts 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 which is an early indication of inhalation anthrax? Hemorrhage Signs of shock Correct Answer Flulike symptoms 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 61/109 You Answered Respiratory distress Rationale: Inhalation anthrax is caused by the inhalation of spores from Bacillus anthracis, which multiply in the alveoli. This form of anthrax begins with the same symptoms as the flu, including fever, muscle aches, and fatigue. Symptoms suddenly become more severe with the development of breathing problems and shock. Toxins from the anthrax spores cause hemorrhage and destruction of lung tissue. Test-Taking Strategy: Focus on the data in the question, and note the strategic word “inhalation.” This will assist you in eliminating the options that indicate hemorrhage and signs of shock. To select from the remaining options, note the word “early,” which will direct you to the correct option. Review the signs of inhalation anthrax if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Biological/Chemical Warfare Question 56 1 / 1 pts A post office employee with suspected skin anthrax asks the emergency department nurse whether the infection is curable. What is the appropriate response by the nurse? “You really need to ask your health care provider about that.” “That’s hard to say. We won’t know for a week or two.” “Antibiotic therapy is usually prescribed and will cure the infection.” Correct! 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 62/109 “It is not curable, but fortunately, unlike inhalation anthrax, it is not deadly.” Rationale: Skin anthrax starts with an itchy bump (papule) that looks like a mosquito bite. It progresses to a small fluid-filled sac that becomes a painless ulcer with an area of dead black tissue in the middle. (Toxins from the anthrax spores destroy surrounding tissue.) Antibiotic treatment cures this infection, but untreated skin anthrax can result in overwhelming septicemia and death. Replying, “You really need to ask your health care provider about that” or “That’s hard to say. We won’t know for a week or two” is nontherapeutic and places the client’s question on hold. Stating, “It is not curable, but fortunately, unlike inhalation anthrax, it is not deadly” is incorrect. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques to eliminate the options that place the client’s question on hold. To select from the remaining options, note that the correct option is the only one that directly addresses the client’s question. Review skin anthrax and therapeutic communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Biological/chemical warfare Ques 1 / 1 pts tion 57 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 Correct! Inhalation 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 63/109 Gastrointestinal Through open wounds Rationale: Smallpox, transmitted in air droplets and in the handling of contaminated materials, is highly contagious. Symptoms include fever, back pain, vomiting, malaise, and headache, followed 2 days later by the appearance of papules that progress to pustular vesicles, which are initially abundant on the face and extremities. Enteric, gastrointestinal, and open wounds are not routes of smallpox transmission. Test-Taking Strategy: Specific knowledge regarding the subject, the route of transmission of smallpox, is necessary to answer this question. Remember that smallpox is transmitted in air droplets and through the handling of contaminated materials. Review the characteristics of smallpox if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Infection Control Question 58 0.75 / 1 pts A client with paraplegia has spasticity of the leg muscles. Which interventions does the nurse expect to be included in the plan of care for this client? Select all that apply. The use of restraints to immobilize the limbs Correct! Range-of-motion exercises of the affected limbs Correct! An as-needed prescription for a muscle relaxant 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 64/109 Correct Answer Removal of potentially harmful objects near the client The use of padding against the client’s legs when the client is sitting in a wheelchair Correct! Ques 1 / 1 pts tion 59 A military nurse who is in charge of planning a vaccination clinic to administer the smallpox vaccine to military personnel is preparing a pamphlet that sets forth guidelines for care of the vaccination site. Which guideline should the nurse include in the pamphlet? Soak the scab that forms with warm water every day. Keep the vaccination site open to air as much as possible. Apply an antihistamine ointment to the scab to prevent itching. Avoid sharing towels or other items that have come in contact with the vaccination site. Correct! 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 65/109 Rationale: A scab will form in the spot where the vaccination was administered. This scab should be left alone so that the vaccinia virus in the vaccine does not spread to other parts of the body. The site is loosely covered with a gauze bandage; this bandage, in turn, is covered with a waterproof bandage during bathing. Clothing is worn over the vaccination site as an extra precaution. The hands must be washed frequently, including whenever the site is touched or the bandage is changed; the vaccinee should not touch the eyes or any other part of the body after changing the bandage or touching the vaccination site. The vaccinee must avoid scratching or putting ointment on the vaccination site. The vaccinee is told to avoid sharing towels and to launder items that have touched the vaccination site because of the risk of spread of the vaccina virus. Test-Taking Strategy: Use knowledge of the subject, care of the smallpox vaccination site, to assist you with the process of elimination. Recalling that the scab should be left alone so that the vaccinia virus in the vaccine doesn’t spread to other parts of the body will direct you to the correct option. Review care of the vaccination site after a smallpox vaccination if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Infection Control Question 60 1 / 1 pts An older client in a long-term care facility is at risk for injury because of confusion. Which device would be the best choice to help prevent injury while the client is in bed? 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 66/109 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 67/109 Correct! 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 68/109 Rationale: If the client is confused, the least intrusive method of restraint is the use of a bed alarm such as the Bed-Check bed exit alarm device. It consists of a weightsensitive mat, placed on the client’s mattress, that sounds an alarm when the sensor detects the removal of pressure. A belt restraint secures the client to the bed or stretcher. It restrains the center of gravity and prevents the client from sitting up on or rolling off a stretcher or falling out of bed. The extremity (ankle or wrist) restraint is used to immobilize an extremity as a means of protecting the client from injury resulting from a fall or the accidental removal of a therapeutic device such as a Foley catheter. The mitten restraint is a thumbless mitten device that is used to restrain the client’s hand. It prevents the client from dislodging invasive equipment, removing dressings, or scratching himself or herself. Test-Taking Strategy: Use the process of elimination and knowledge of the various restraint methods and the ethical and legal ramifications of using a restraint. The use of the strategic words “best choice” will guide you to the correct option. Also recall that the least invasive method of restraint should be used; this will help you answer correctly. Review the guidelines for the use of restraints if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Question 61 1 / 1 pts A nurse recognizes the need to place wrist restraints on a client, but the client does not want the restraints applied. Which is the appropriate nursing action? Correct! Contact the health care provider. Apply the restraints anyway 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 69/109 Medicate the client with a sedative, then apply the restraints Compromise with the client and use only one wrist restraint instead of two Rationale: The use of restraints must be avoided if possible. If it is determined that a restraint is necessary, the nurse should discuss the issue with the family and obtain a prescription from the health care provider. The nurse should explain carefully to the client and family the reasons that the restraint is necessary, the type of restraint that has been selected, and the anticipated duration of use of the restraint. If a client refuses restraints, the nurse must contact the health care provider. Therefore the other options are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that involve the application of restraints. Noting the strategic word “appropriate” will also assist you in answering correctly. Review the ethical and legal guidelines for the use of restraints if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Ques 1 / 1 pts tion 62 After discussing the use of restraints with a client and family, a health care provider has written a prescription for wrist restraints to be applied to a client. The nurse instructs the nursing student to apply the restraints. Which observations by the nurse indicates that the nursing student is using the restraints safely and correctly? Select all that apply. The restraints are applied tightly. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 70/109 Correct! The restraints are being released every 2 hours. Correct! A safety knot has been used to secure the restraints. The restraints have been tied to the siderails of the bed. Correct! The call light has been placed within reach of the client. Rationale: Restraints should never be applied tightly, because this could impair circulation. They should be tied to the bed frame (not the siderail) with the use of a safety knot. The client could sustain injury if the siderail were lowered with a restraint attached to it. A safety knot is used because it can easily be released in an emergency. Restraints must be released every 2 hours to facilitate inspection of the skin, help ensure good circulation, and permit movement of the joint through its range of motion. The call light must always be within reach of the client in case he or she needs assistance. Test-Taking Strategy: Focus on the subject, the delivery of safe care by the nursing student. Think about the guidelines for the use of restraints. Note the word “tightly” and “tied to the siderails” in the incorrect options. Review the guidelines for the use of restraints if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Leadership/Management Question 63 1 / 1 pts 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? 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 71/109 Remove both restraints. Correct! Remove a restraint from one extremity. Tell the mother that the restraints may not be removed. Loosen the restraints after telling the mother that they may not be removed. Rationale: Elbow restraints are used after cleft palate repair to prevent the child from touching the repair site, which could cause rupture or tearing of the sutures. The restraints may be removed one at a time only with a parent or nurse in constant attendance. Removing both restraints, telling the mother that the restraints may not be removed, and loosening the restraints are all incorrect nursing actions. Test-Taking Strategy: Eliminate the comparable or alike options that indicate that the restraints may not be removed. To select from the remaining options, recall the purpose of the restraints after this surgical procedure. This will direct you to the correct option, the safe nursing action. Also note the word “both” in the incorrect option. Review nursing interventions after cleft palate repair if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Ques 1 / 1 pts tion 64 A community health nurse is asked to assist in developing a community disaster plan. The nurse determines that this responsibility is a component of which disaster management phase identified by the Federal Emergency Management Agency (FEMA)? 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 72/109 Response Recovery Mitigation Correct! Preparedness Rationale: The preparedness phase has many functions, including planning for rescue, evacuation, and caring for disaster victims; the training of disaster personnel and gathering of resources, equipment, and other materials needed in dealing with a disaster; identifying specific responsibilities for various disaster response personnel; establishing a community disaster plan and an effective public communication system; setting up an emergency medical system and a plan for its activation; checking for proper function of emergency equipment; making anticipatory provisions and setting up a location for food, water, clothing, medication, shelter, and other supplies; checking supplies on a regular basis and replenishing outdated materials; and practicing community disaster plans (mock-disaster drills). The mitigation phase refers to actions or measures to either prevent the occurrence of a disaster or reduce the damaging effects of a disaster. The response phase includes putting disaster planning services into action and the actions taken to save lives and prevent further damage. The recovery phase includes actions taken to return to a normal situation after the disaster. Test-Taking Strategy: Use the process of elimination. Note the relationship between the subject, developing a community disaster plan, and the correct option, preparedness. Review the four disaster management phases if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Disasters 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 73/109 Question 65 1 / 1 pts A nurse is admitting a postoperative client from the postanesthesia care unit to the surgical nursing unit. Which measure should the nurse take for the safety of the client? Asking the client to slide from the stretcher to the bed Quickly moving the client from the stretcher to the bed Putting the siderails up after moving the client from the stretcher Correct! Uncovering the client before making the transfer from the stretcher to the bed 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 74/109 Rationale: Because the client may be experiencing residual effects of anesthesia, the nurse should raise the siderails after transferring the client from the stretcher to the bed. Agency policy for the use of siderails is always followed; some agencies’ policies set forth the number of siderails that may be used. Because of the effects of anesthesia and postoperative pain, it is not realistic to ask the client to slide from the stretcher to the bed. Hurried movements and rapid changes in position should be avoided because they may trigger orthostatic hypotension. The nurse should avoid exposing the postoperative client during transfer because of the potential for heat loss, respiratory infection, and shock. Test-Taking Strategy: Use knowledge of the subject, client safety, to assist you with the process of elimination. First eliminate the options that are not standard nursing interventions. Choose from the remaining options knowing that the subject of the question is client safety. Noting the words “asking the client to slide,” “quickly,” and “uncover” will help you eliminate these options. Review care of the postsurgical client if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Question 66 1 / 1 pts 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. Correct! “Change positions slowly.” Correct! “Remove clutter from your home.” “Use public transportation as much as possible.” 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 75/109 “Drive your car only if you’re not feeling dizzy.” “Turn your head slowly when someone speaks to you.” Rationale: Any sudden movement could precipitate a vertigo attack, so to help prevent vertigo attacks, the client should avoid such movements. The client with chronic vertigo should avoid driving; the use of public transportation should also be avoided because of the sudden movements that occur with this mode of transport. The client should also change position slowly and should turn the entire body, not just the head, when spoken to. If vertigo does occur, the client should immediately sit down or grasp the nearest piece of stable furniture. The client should maintain the home in a state free of clutter and remove throw rugs, because the effort of trying to regain balance after slipping could trigger the onset of vertigo. Test-Taking Strategy: Focus on the subject, safety measures for a client with chronic vertigo. Read each option carefully. Thinking about general safety principles and those that are important for a client with chronic vertigo will help you answer correctly. Review safety measures for the client with chronic vertigo if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Question 67 1 / 1 pts 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. Correct! A victim with a limb amputation 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 76/109 Correct! A victim who is alert but complaining of loss of vision Correct! A victim who is bleeding profusely from a head laceration 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 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 77/109 Rationale: The emergent designation (a.k.a. red or priority 1), the highest priority, is assigned to the victim who has sustained life-threatening injuries and requires immediate attention and continuous evaluation yet has a high probability of survival once his or her condition has been stabilized. In this scenario, emergent status should be assigned to the victim with a limb amputation, the victim with vision loss, and the victim who is bleeding profusely. The urgent designation (a.k.a. yellow or priority 2) is given to the victim who requires treatment but whose injuries and their complications are not life threatening, provided that they are treated within 1 to 2 hours. The victim who is dazed and staggering around the other victims may be assigned to this category because it is possible that the client has sustained a head injury. The nonurgent (a.k.a. green or priority 3) designation is given to the victim with local injuries who does not exhibit immediate complications and who will be able to wait several hours for medical treatment; such victims require evaluation every 1 to 2 hours thereafter. In this scenario, the victim who has sustained minor bruises of the arm and lower legs would be assigned to this category. Test-Taking Strategy: Focus on the subject, the victims that would be assigned to the emergent category. Use the ABCs—airway, breathing, and circulation—to identify the victim with a limb amputation and the victim bleeding profusely from a head laceration as belonging in the emergent category. Noting that another victim has lost vision will help you determine that this victim requires emergency care. Review the triage classification system used in the ED if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Question 68 1 / 1 pts 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 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 78/109 the nurse understand is most appropriate to help ensure the safety of this client? Doubling the dose of anticoagulant Applying a pressure bandage to the site after each IM injection Applying prolonged pressure to the sites of the IM and SC sites Correct! Decreasing the length of the needles used for the IM and SC injections Rationale: The use of anticoagulants puts the client at risk for bleeding. Prolonged pressure over the site of an IM injection will help prevent bleeding into the tissues surrounding the injection site. Doubling the dose of anticoagulants is incorrect. Decreasing the needle sizes may be helpful but is not necessary. A pressure bandage is not an appropriate measure and is also unnecessary. Test-Taking Strategy: Use the process of elimination and note the strategic words “most appropriate.” Eliminate the option that involves doubling the dose. Next recall the principles of medication administration, then eliminate the option involving a decrease in needle length. To select from the remaining options, visualize each. It is inappropriate and unnecessary to apply a pressure bandage after each injection. Review safety measures for the client receiving injections and taking an anticoagulant if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Question 69 0 / 1 pts 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 79/109 A nurse who is assisting a client in preparing for discharge is asking questions to determine whether there are any environmental hazards in the home. Which statements, if made by the client, would prompt the nurse to investigate further? Select all that apply. You Answered “I live in a single-story house.” Correct Answer “I don’t have any nightlights in the house.” You Answered “I’ve removed the scatter rugs from the house.” “I keep my personal items within reach when I sit in my easy chair.” “I haven’t changed the batteries in the smoke detectors in my home for quite a few years now.” Correct Answer Rationale: If the client tells the nurse that there are no nightlights in the home, the nurse should further investigate the situation. Nightlights help prevent falls by the client who may need to get up during the night. The batteries in smoke detectors should be changed at least once a year, so the nurse must investigate further if the client indicates that this has not been done for “quite a few years.” The other statements by the client do not reflect environmental hazards in the home. Test-Taking Strategy: Note the strategic words “investigate further.” These words indicate a negative event query and the need to select the statements by the client that indicate the presence of environmental hazards. Reading each option carefully will direct you to the correct options. Review environmental hazards in the home if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Safety 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 80/109 Question 70 1 / 1 pts 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/mm . Which interventions does the nurse implement on the basis of this finding? Select all that apply. 3 Providing a soft toothbrush for oral care Correct! Monitoring the client’s oral temperature Correct! Maintaining sterile occlusion of intravenous (IV) catheters Requiring the client to use an electric shaver rather than a razor Performing meticulous skin decontamination before venipuncture Correct! Avoiding overinflation of the blood pressure cuff and rotating the cuff among several sites when measuring the blood pressure 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 81/109 Rationale: When the neutrophil count falls below 500 cells/mm , the client is at risk for infection. Monitoring of the oral temperature, maintaining sterile occlusion of IV and central venous catheters, and meticulous skin decontamination before venipuncture are critical nursing interventions for the client at risk for infection. The remaining options are interventions that are necessary for the client who has a low platelet count and is at risk for bleeding. Test-Taking Strategy: Focus on the information in the question, and note that the client’s neutrophil count is low. Recalling the relationship between a low neutrophil count and the risk for infection will direct you to the correct options. If you had difficulty with this question, review the nursing plan of care for a client with leukemia who has a low neutrophil count. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control 3 Question 71 1 / 1 pts A client with a new diagnosis of tuberculosis (TB) is being admitted to the hospital. During the collection of data from the client, which consideration is especially important? The religious affiliation or church of preference Correct! The names of close friends and family members What medications have been prescribed and what the client knows about their side effects The name of the person from whom the client contracted TB, so that the person may be reported for follow-up care 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 82/109 Rationale: TB is a contagious disease that is spread in respiratory droplets. The nurse needs to elicit the names of close friends and family members so that these individuals may be tested for exposure to TB. The client’s religious affiliation or church of preference is a component of the data collection process but is not the primary consideration of the options provided. It is premature to determine knowledge regarding medications, because treatment measures may not yet have been prescribed. The client may not know the name of the person from whom the disease was contracted. Test-Taking Strategy: Use the process of elimination and note the strategic words “especially important.” Recalling the route of transmission of TB will direct you to the correct option. Review data collection techniques for the client with a new diagnosis of TB if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Assessment Content Area: Infection Control Unanswered Question 72 0 / 1 pts A client with osteoporosis is at risk for falls. Which statement by the client indicates the need for instruction regarding measures to prevent falls? Correct Answer “I took the bathmat out of my tub.” “I use a shower chair when I bathe.” “I’ve placed nightlights in my hallway.” “The railings on my stairs are sturdy and secure.” 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 83/109 Rationale: Home modifications to reduce the risk for falls include use of sturdy, secure railings on all staircases and ample lighting, including nightlights. Bathroom safety equipment includes a shower chair, handrails in the shower and near the toilet, and a mat in the tub to prevent slipping. Test-Taking Strategy: Note the strategic words “need for instruction.” These words indicate a negative event query and the need to select the incorrect client statement. Begin to answer this question by eliminating the options that involve the provision of physical support to the client, because these measures are needed. Use of a nightlight, which will enhance vision for the client getting up at night to use the bathroom, is also warranted. The only remaining option, which is the correct answer, is removing the bathmat. Remember that mats prevent slips and falls. Review the basic measures for the prevention of falls if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Question 73 1 / 1 pts 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 Respiratory droplets Correct! Close intimate contact 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 84/109 Rationale: Epstein-Barr virus is transmitted by way of contact with infectious saliva, close intimate contact with an infectious individual, or contact with infected blood. The infectious period is unknown, but the virus is commonly shed from before clinical onset of disease until 6 months or longer after recovery. It is not transmitted by way of the fecal-oral route, in airborne particles, or in respiratory droplets. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options (i.e., airborne particles and respiratory droplets). To select from the remaining options, it is necessary to know the route of transmission of infectious mononucleosis. If you are unfamiliar with transmission of the Epstein-Barr virus, review this content. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Infection Control Question 74 1 / 1 pts A teenage client returns to the gynecological (GYN) clinic for a follow-up visit after diagnosis and initial treatment of a sexually transmitted infection (STI). Which statement by the client indicates the need for further teaching? “I finished all the antibiotic, just like you said.” “I know you won’t tell my parents that I’m sick.” “I always make sure my boyfriend uses a condom.” Correct! “My boyfriend doesn’t have to come in for treatment.” 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 85/109 Rationale: In the treatment of STIs, all sexual contacts must be alerted and treated with medication. Any treatment at a GYN clinic for teenagers is confidential, and parents will not be contacted even if the client is under 18 years. The client should always finish the medication prescribed by the health care provider. Every client who is being treated for an STI or is at risk for an STI should use a condom for any sexual contact Test-Taking Strategy: Note the strategic words “need for further teaching.” These words indicate a negative event query and the need to select the incorrect client statement. Read each option carefully. Using knowledge of safe sex practices and the treatment of STIs will help you answer this question. Review content related to the transmission of STIs if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Infection Control Question 75 1 / 1 pts A nurse has provided instructions to a mother regarding the use of safety seats in car travel for her newborn infant. Which statement by the mother indicates understanding of the instructions? “I’ll put the baby’s car seat in the front seat, facing forward and reclined a little.” “I’ll put the baby’s car seat in the front seat, facing backward and reclined a little.” “I’ll put the baby’s car seat in the middle back seat, facing forward and reclined a little.” 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 86/109 “I’ll put the baby’s car seat in the middle back seat, facing backward and reclined a little.” Correct! Rationale: The infant should be restrained in a car seat in a semireclined, rear-facing position to allow the seat and infant’s spine to bear the forces of impact should a collision occur. The infant should never face forward or ride in the front seat. Test-Taking Strategy: Use knowledge of the subject, infant car seat safety, to assist you with the process of elimination. Visualize each of the descriptions in the options with safety in mind. Recalling that an infant should not be placed in the front seat or in a forward-facing position will direct you to the correct option. If you had difficulty with this question, review car safety measures for the infant. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Safety Ques 0 / 1 pts tion 76 During a laboratory training session, the nurse is watching as a nursing assistant repositions a client. Which observation tells the nurse that further training is necessary? The nursing assistant positions himself close to the client. The nursing assistant keeps his neck, back, pelvis, and feet aligned. You Answered The nursing assistant encourages the client to assist as much as possible. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 87/109 The nursing assistant keeps his knees straight and his feet close together. Correct Answer Rationale: To help prevent injury, the nurse needs to use and encourage staff members to use good body mechanics and ergonomic principles in providing care. When planning to reposition a client, the staff member must assess the client’s ability to assist and encourage the client to assist as much as possible. The nursing assistant should position himself close to the client and keep the back, neck, pelvis, and feet aligned, avoiding twisting; use the arms and legs (not the back); and keep the knees flexed and the feet wide apart. Test-Taking Strategy: Note the strategic words “further training is necessary.” These words indicate a negative event query and the need to select the unsafe action by the nursing assistant. Think about ergonomics and the principles of good body mechanics as you visualize each option. If you had difficulty with this question, review the principles of good body mechanics. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Ques 1 / 1 pts tion 77 A nurse preparing to perform a sterile dressing change notes that the covering of a package of sterile 4 × 4 gauze pads has a small tear. Which action should the nurse take? Correct! Discarding the package Using the gauze pads because the tear was small 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 88/109 Examining the gauze pads and using them as long as they appear untouched Discarding the gauze pad closest to the outside of the package and using the others Rationale: When performing a surgically aseptic procedure, the nurse must follow certain principles of aseptic technique to ensure maintenance of asepsis. A sterile object remains sterile only when touched by other sterile objects. If the sterile state of an object is questionable (e.g., if there is a tear or break in the covering of a sterile object), the nurse must discard the object because it is considered contaminated. Therefore the nurse in this situation would not use the gauze pads. Test-Taking Strategy: Focus on the data in the question, and note that the package of sterile gauze is torn. Also note that the incorrect options are comparable or alike in that they indicate that it is acceptable to use the gauze in the package. If you had difficulty with this question, review the principles of aseptic technique. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control Question 78 0 / 1 pts A nurse employed on a medical care unit is administering medications. She tells a client that she is going to administer his furosemide (Lasix) through his intravenous (IV) line. The client tells the nurse that he takes this medication orally at home every day and is concerned that it is being administered by way of a different route. The nurse should take which most appropriate action? 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 89/109 You Answered verifying the prescription Correct Answers Verifying the health care provider’s prescription Sitting and talking to the client to alleviate his concern Explaining to the client that the oral route will not permit the medication to exert an adequate effect Letting the client know that most medications are administered by way of the IV route when a client is hospitalized Rationale: If the client questions a health care provider’s prescription, the nurse must verify the prescription. This is the most appropriate action. Although it is appropriate to talk to the client and alleviate concerns, this is not the most appropriate action of those provided. Although in some client situations the IV route of administration of certain medications is more effective than the oral route, providing the client with this information is not the most appropriate action of the options provided. Critical care units in the hospital may administer most medications by way the IV route, but this is not necessarily the situation in a medical care unit. Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Noting that the client is questioning the route of administration of the medication will direct you to the correct option. Remember to always verify a prescription if the client questions it. If you had difficulty with this question, review nursing responsibilities related to the administration of medications. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 79 0.33 / 1 pts 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 90/109 At the beginning of the 7 a.m. to 3 p.m. shift, the nurse checks her assigned clients and notes that a client with diabetes mellitus has an intravenous (IV) bag of 5% dextrose in water hanging and infusing instead of the prescribed 0.9% normal saline. The nurse verifies the prescription and changes the IV solution to the correct one. The nurse assesses the client noting that the blood glucose level at 7:15 a.m. was 149 mg/dL, notifies the health care provider, and completes an incident report. Which information about the event is appropriate for inclusion on the incident report? Select all that apply. INCIDENT REPORT Events That Occurred Correct! The health care provider was contacted. Correct! The blood glucose level at 7:15 a.m. was 149 mg/dL. Correct Answer An IV solution of 5% dextrose in water was infusing at 7 a.m. A solution of 5% dextrose in water was infusing instead of the prescribed 0.9% normal saline solution. You Answered A 5% dextrose in water solution is not usually prescribed for clients with diabetes, and the solution was changed immediately on its discovery. Question 80 1 / 1 pts A nurse performs an evaluation to determine whether a client’s home is electrically safe. Which finding indicates the need for further investigation and intervention? Correct! Wiring for the television runs under the carpet. Electrical cords are free of frayed and damaged wires. Electrical kitchen appliances are located away from the sink. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 91/109 A safety-type extension cord is secured to the floor with electrical tape. Rationale: Electrical safety guidelines must be followed to help prevent fires and injuries. These guidelines include the maintaining of electrical equipment in good working order with proper grounding; periodically checking electrical cords and outlets for exposed, frayed, or damage wires and loose or missing parts; avoiding overload of electrical circuits; reading warning labels on all equipment; never operating unfamiliar equipment; using safety-style extension cords and using such cords only when absolutely necessary, securing them to the floor with electrical tape; never running electrical wiring under a carpet; never pulling a plug by the cord; never using electrical appliances near sinks, bathtubs, or other water sources; and disconnecting a plug from the outlet before cleaning the equipment or appliance to which it is attached. Test-Taking Strategy: Note the strategic words “need for further investigation and intervention.” These words indicate a negative event query and the need to select the unsafe finding. Note the words “runs under the carpet” in the correct option. If you had difficulty with this question, review electrical safety guidelines. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Safety Ques 1 / 1 pts tion 81 Which safety guidelines should the nurse include in the plan of care for a client with an internal radiation implant? Select all that apply. Correct! Wear a lead shield when in the client’s room. 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 92/109 Limit visits from family to 60 minutes per day. Correct! Wear a dosimeter film badge when in the client’s room. Allow children to visit the client as long as they are at least 12 years old. Keep all bed linens and dressings in the client’s room until the implant is removed. Correct! Rationale: Nursing responsibilities in the care of a client with an internal radiation implant, which involve preventing exposure to the radiation, include placing the client in a private room with a private bath; rotating nursing assignments and organizing nursing tasks to minimize exposure to the radiation source; limiting time to 30 minutes per care provider per shift; wearing a dosimeter film badge to measure radiation exposure; wearing a lead shield to reduce the transmission of radiation; not allowing pregnant women or children younger than 16 years to visit the client; limiting visitors to 30 minutes per day (visitors should stay at least 6 feet from the source); keeping all bed linens and dressings in the client’s room until the implant is removed; keeping a lead container in the client’s room for housing the implant if it should be dislodged; and avoiding touching a dislodged radiation source (longhandled forceps are used to place the source in the lead container). Test-Taking Strategy: Focus on the subject, safety guidelines for the client with an internal radiation implant. Recalling that the goal of care is to prevent exposure to the radiation will direct you to the correct options. If you had difficulty with this question, review radiation safety guidelines. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Safety 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 93/109 Question 82 1 / 1 pts A sedated client is being transported to the radiology department on a stretcher. Which type of restraint should the nurse suggest applying to help ensure the client’s safety? Correct! Belt Wrist Elbow Mitten Rationale: A belt restraint is a device that is wrapped around the client’s waist to secure the client to bed or to a stretcher. An elbow restraint consists of a piece of fabric with slots into which tongue blades are inserted; the device is wrapped around the elbow area to keep it immobile. A mitten restraint is a thumbless device that covers the client’s hand and is used to restrain the client’s hand, preventing the client from dislodging invasive equipment (e.g., an intravenous line). A wrist restraint is a device used to immobilize an arm that does not allow movement as a mitten restraint would. Test Taking Strategy: Focus on the data in the question, and note the strategic word “best.” Noting the words “sedated” and “on a stretcher” will help direct you to the correct option. Review the types of restraints and their uses if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Question 83 0 / 1 pts 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 94/109 A hospitalized client, experiencing confusion, is at risk of falling because she continually tries to climb out of bed. Which of these safety devices that the nurse might suggest is the least restrictive? Belt You Answered Wrist Elbow Correct Answer Ambularm Rationale: The Ambularm device, worn on the leg, signals when the client’s leg is in a dependent position. It is used for clients who climb out of bed and are at risk for falling. Ambularm devices that may be attached to the bed or chair or to the client's mattress or nightgown are also available. A belt restraint is a device that is wrapped around the client’s waist to secure the client to bed or to a stretcher. A wrist restraint is a device used to immobilize an arm. An elbow restraint consists of a piece of fabric with slots into which tongue blades are inserted, after which the device is wrapped around the elbow area to immobilize it. Of the options provided, the Ambularm is the least restrictive safety device. Test-Taking Strategy: Note the strategic words “least restrictive.” Read each option, and think about where it would be applied to the client and how it might affect the client’s mobility; this will direct you to the correct option. If you had difficulty with this question, review the various types of security devices and how they affect a client’s movement. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 95/109 Question 84 1 / 1 pts Which points should the nurse include when documenting information about a client who is wearing wrist restraints? Select all that apply. The client’s temperature The client’s 24-hour urine output Correct! Skin integrity of the restrained body part Correct! The procedure used in applying the restraint Correct! The date and time of application of the restraint Circulatory and neurovascular status of the restrained extremities Correct! 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 96/109 Rationale: The nurse is responsible for documenting specific information about the client who is wearing any type of restraint. The points that must be included in such documentation are the reason for the restraint; alternatives to the restraint that were used; the method of restraint; the procedure used in applying the restraint; date and time of application of the restraint; client's response to application of the restraint; condition of the restrained body part; assessment of circulatory, neurovascular, and skin integrity; periodic release from restraint with movement or range-of-motion exercise; assessment of the need for continued use of the restraint; the duration of use of the restraint; and the client's response on removal of the restraint. Test-Taking Strategy: Focus on the subject, documentation points for a client with restraints. Read each option carefully to determine its association with the use of restraints. Also note that the correct options make specific reference to restraints. Review documentation of the use of restraints if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Ethical/Legal Question 85 1 / 1 pts The nurse is conducting inservice education for newly hired nursing assistants covering the topic of standard precautions. The nurse should explain that which actions are in keeping with the principles of standard precautions? Select all that apply. Correct! Handwashing between client contacts Cleaning of blood spills with soap and warm water Correct! Discarding needles in puncture-resistant containers 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 97/109 Handwashing before removal of a pair of soiled gloves Wearing a face shield as a part of the protective garb during a wound irrigation Correct! Wearing a gown and gloves when changing the linens on the bed of a client with a draining lesion of the leg Correct! Rationale: Standard precautions must be practiced with all clients in every setting. These precautions involve handwashing and the use of gloves, masks, eye protection, and gowns, as well as other protective devices, when they are appropriate for client contact. These precautions apply to contact with blood, body fluids, nonintact skin, and mucous membranes. The hands are always washed between client contacts and after (not before) gloves are removed. Needles are not recapped (unless the agency provides special and agency-approved recapping devices for health care providers) and are discarded in puncture-resistant containers. Spills of blood or body fluids are cleaned up with a solution of bleach and water (diluted 1:10) or other agency-approved disinfectant. A mask, eye protection, or face shield is worn if client care activities have the potential to result in splashes or spraying of blood or body fluid. A gown is worn if soiling of clothing is likely. Test Taking Strategy: Focus on the subject, standard precautions. Think about the purpose of standard precautions and visualize each of the options. This will help you answer correctly. Review the principles of standard precautions if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control Question 86 0.8 / 1 pts 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 98/109 A nurse is reading the history and physical examination findings of an older client who has just been admitted to the hospital. Which findings documented in the history indicate an increased risk for accidents? Select all that apply. Correct! The client’s range of motion is limited. Correct! Transmission of heat impulses is delayed. Correct! The client’s peripheral vision is decreased. Correct! The client complains of frequent nocturia. High-frequency hearing tones are perceptible. Correct Answer Voluntary and autonomic reflexes are slowed. Question 87 1 / 1 pts 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 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 99/109 Tuberculosis Correct! Pharyngeal diphtheria Correct! Streptococcal pharyngitis Correct! Meningococcal pneumonia Rationale: A standard mask is used as part of droplet precautions to protect the nurse from acquiring the client’s infection. Droplet precautions are those precautions used to help prevent the spread of organisms that can spread through the air but are unable to remain in the air farther than 3 feet from the source. Many respiratory viral infections require the use of a standard mask during client care. Some of the disorders requiring the use of a standard mask are pharyngeal diphtheria; rubella; streptococcal pharyngitis; pertussis; mumps; pneumonia, including meningococcal pneumonia; and pneumonic plague. Scabies and hepatitis A, transmitted by way of direct contact with an infected person, require the use of contact precautions for protection. Tuberculosis requires airborne precautions and the use of an individually fitted particulate filter mask. A standard mask would not protect the nurse from Mycobacterium tuberculosis. Test-Taking Strategy: Focus on the data in the question, noting the figure, and note that it depicts a nurse donning a standard mask. This indicates the need for the nurse to protect himself or herself from inhaling an organism. You can eliminate tuberculosis by recalling that tuberculosis requires the use of an individually fitted particulate filter mask. Next eliminate the comparable or alike options (i.e., scabies and hepatitis A virus) in that these disorders are not transmitted by way of the respiratory route. Also note that the correct options are respiratory infections. Review the indications for the use of a standard mask if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 100/109 Question 88 1 / 1 pts Wrist restraints have been prescribed for a client who is constantly pulling at his gastrostomy tube. Which findings does the nurse, following a care plan, recognize as unexpected outcomes related to the use of restraints? Select all that apply. Correct! The client is agitated. Correct! The skin under the restraint is red. Correct! The client’s left hand is pale and cold. The client verbalizes the reason for the restraints. 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. Correct! 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 101/109 Rationale: A physical restraint is a mechanical or physical device used to immobilize a client or extremity. The restraint restricts freedom of movement. Unexpected outcomes in the use of restraints include signs of impaired skin integrity, such as redness or skin breakdown; altered neurovascular status, such as cyanosis, pallor, coldness of the skin, or complaints of tingling, numbness, or pain; increased confusion, disorientation, or agitation; and escape from the restraint device that results in a fall or injury. Client verbalization of the reason for the restraints and the client’s inability to reach the gastrostomy tube with his hands are expected outcomes. Test-Taking Strategy: Note the strategic word “unexpected.” This word indicates a negative event query and asks you to select the options that indicate undesirable effects of the use of the restraints. Focusing on the data in the question and recalling the nursing responsibilities in the care of a client in restraints will help you answer the question. Review expected and unexpected findings related to the use of restraints if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Safety Question 89 1 / 1 pts A nurse is discussing accident prevention with the family of an older client who is being discharged from the hospital after hip surgery. Which items in the home increase the client’s risk for injury? Select all that apply. A nightlight in the bathroom Elevated toilet seat with armrests Correct! Cooking equipment such as a stove 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 102/109 Smoke and carbon monoxide detectors Correct! Common household objects such as doormats A water heater thermostat adjusted to a low setting Rationale: Physical hazards in the environment place the client at risk for accidental injury and death. Adequate lighting, such as nightlights in dark hallways and bathrooms, reduces the physical hazard by illuminating areas in which a person moves about. An elevated toilet seat with armrests and nonslip strips on the floor in front of the toilet are useful in reducing the incidence of falls in the bathroom. Cooking equipment and appliances, particularly stoves, are a major cause of fires and related injuries in the home. Smoke and carbon monoxide detectors should be placed throughout the home to alert members of the household to danger. A low thermostat setting on the water heater reduces the risk of burns during the use of hot water (e.g., bathing or showering). Injuries in the home are often the result of tripping over or coming into contact with such common household objects as a doormats, small rugs on the floor or stairs, and clutter around the house. Test-Taking Strategy: Read each option carefully. Focus on the subject of the question, the physical factors that put the client at risk for injury at home. Next think about whether the factor is safe or presents a potential for injury; this will help you answer the question. Review the physical factors that increase a client’s risk for injury at home if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Question 90 1 / 1 pts 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 103/109 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 actions should the nurse take to determine the client’s safety risk? Select all that apply. Correct! Assessing the client’s visual acuity Correct! Observing the client’s gait and posture Correct! Evaluating the client’s muscle strength Correct! Looking for any hazards in the home environment Asking a family member to move in with the client until her recovery is complete Requesting that the client transfer to an assisted living environment for at least 1 month 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 104/109 Rationale: To assist with data collection, the nurse looks for risk factors related to safety. The nurse should collect data on visual acuity, gait and posture, and muscle strength because alterations in these areas increase the client’s risk for falls and injury. The nurse should also examine the home environment, looking for any hazards or obstacles that might affect safety. Asking a family member to move in with the client until recovery is complete and requesting that the client transfer to an assisted living environment for at least 1 month are not assessment activities. Additionally, nothing in the question indicates that these actions are necessary; therefore, these options are unrealistic and unreasonable. Test-Taking Strategy: Focus on the subject, monitoring for risk factors related to safety. Read each option carefully and note that the incorrect options are unrelated to the subject of the question. Review the items that should be included in data collection for home safety if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Data Collection Content Area: Safety Question 91 1 / 1 pts The nurse has conducted a review of sterile technique for colleagues in the operating room. Which statements by the team members reflect understanding of the principles of sterile technique? Select all that apply. The edge of a sterile field and a border 1 inch inward is unsterile. Correct! If a package is not labeled as sterile, it should be considered unsterile. Correct! 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 105/109 Sterile objects that come in contact with unsterile objects are to be considered contaminated. Correct! Any part of a sterile field that hangs below the top of the table is sterile as long as it is not touched. When a sterile field becomes wet, it remains sterile as long as the items on the field are not touched. Items in a sterile package must be used immediately once the package has been opened; otherwise they are considered contaminated. Correct! Rationale: The term sterile means the absence of all microorganisms. To maintain sterile technique, the nurse must follow several principles. Among these principles: The edge of a sterile field and 1 inch inward is unsterile; sterile packages are labeled as sterile and, if the package is not so labeled, it is considered unsterile; sterile objects that come in contact with unsterile objects are considered contaminated; any part of a sterile field that falls or hangs below the top of the table is unsterile; a sterile field that becomes wet will draw microorganisms from the surface beneath, contaminating the field; and items in a sterile package must be used immediately once the package has been opened, or they will be considered contaminated. Test-Taking Strategy: Focus on the subject, the accurate principles of sterile technique. Visualize each of the options and think about the principles of sterility to assist in answering the question. Note the words “hangs below the top of the table” and “becomes wet” in the incorrect options. Review these principles of sterile technique if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Infection Control 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 106/109 Question 92 0.67 / 1 pts Which actions are means of maintaining medical asepsis to reduce and prevent the spread of microorganisms? Select all that apply. Correct! Practicing hand hygiene You Answered Reapplying a sterile dressing Sterilizing contaminated items Applying a sterile gown and gloves Correct! Routinely cleaning the hospital environment Wearing clean gloves to prevent direct contact with blood or body fluids Correct! Ques 1 / 1 pts tion 93 Which interventions does a nurse, reviewing infection control interventions with the nursing staff, tell the staff will reduce reservoirs of infection? Select all that apply. Correct! Keeping bedside table surfaces clean and dry Placing tissues and soiled dressings in paper bags Correct! Changing dressings that become wet or soiled Placing capped needles and syringes in puncture-resistant containers 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 107/109 Using soap and water to remove drainage, dried secretions, or excess perspiration from a client’s skin Correct! Emptying urinary drainage systems (Foley catheter drainage) on each shift unless prescribed otherwise by a health care provider Correct! Rationale: Measures to reduce reservoirs of infection include keeping bedside table surfaces clean and dry; placing tissues, soiled dressings, and soiled linens in moisture resistant bags (not paper bags); changing dressings that become wet or soiled; placing syringes and uncapped (not capped) needles in puncture-resistant containers; using soap and water to remove drainage, dried secretions, or excess perspiration from a client’s skin; and emptying all drainage systems on each shift unless prescribed otherwise by a health care provider. Test-Taking Strategy: Focus on the subject, interventions to reduce reservoirs of infection. Read each option carefully; note the words “paper” and “capped” in the incorrect options. Review interventions that will reduce reservoirs of infection if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Infection Control Question 94 1 / 1 pts A nurse is performing sterile wound irrigation for an assigned client. A nursing assistant enters the client’s room and tells the nurse that a health care provider has telephoned and has asked to speak to the nurse. What is the appropriate action by the nurse? Asking the nursing assistant to take a message 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 108/109 Covering the client and answering the telephone call Finishing the wound irrigation while the health care provider waits on the telephone Asking the nursing assistant to obtain a telephone number from the health care provider so that the nurse may return the call after the wound irrigation is complete Correct! Rationale: Because wound irrigation is a sterile procedure and a risk for infection exists with any open wound, the nurse should ask the nursing assistant to obtain a telephone number from the health care provider so that the call may be returned after the wound irrigation is complete. It is not appropriate to ask a health care provider to wait while a procedure is being completed. It is best to return the call. It is not the responsibility of the nursing assistant to take a message. Test-Taking Strategy: Note the strategic word “appropriate,” and use your knowledge of the priorities of care. Recalling that a wound irrigation is a sterile procedure and that a risk for infection exists with any open wound will direct you to the correct option. Remember that the client is the priority and must be protected from the risk of infection. With that in mind, you must select the option of returning the call to the health care provider once the irrigation is complete. Review the principles of priorities of care if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Infection Control Question 95 1 / 1 pts A nurse is watching as a newly hired nurse suctions a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83900?module_item_id=1519722 109/109 Which protective devices worn by the newly hired nurse would cause the nurse to determine that the new employee was performing the procedure safely? Gloves and mask Gloves and gown Correct! Gloves, gown, and face shield. Gown and protective eyewear Rationale: Standard precautions include use of gloves whenever there will be actual contact with blood or body fluids or the potential for contact exists. Therefore the nurse must wear gloves. The nurse also needs to protect the eyes, nose, and mouth from contact with the client’s respiratory secretions; a face shield will provide this protection. A mask or protective eyewear does not provide adequate protection. Gowns are worn in those instances when it is anticipated that there will be contact with body fluid or blood. Test-Taking Strategy: Note that the question addresses suctioning, so remember that airborne secretions and possibly airborne particles of blood are a possibility with this procedure. Basic knowledge of the subject, standard precautions, should guide you to look for an option that includes adequate protection during this procedure. This will direct you to the option that includes a face shield as one of the necessary protective items. If you had difficulty with this question, review standard precautions and the procedure for suctioning. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Leadership/Management Quiz Score: 85.22 out of 95 [Show More]

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