HESI Fundamentals

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1. Which client care task requires the nurse to wear barrier gloves as mandated by the Standard Precautions protocol?

A. Removing the empty food tray from a client with a urinary catheter.
B. Washing and combing the hair of a client with a fractured leg in traction.
C. Administering oral medications to a cooperative client with a wound infection.
D. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

Correct answer: D

Rationale: The correct answer is D because emptying a urinary catheter drainage bag exposes the nurse to body fluids, necessitating the use of barrier gloves as per Standard Precautions to prevent potential infection transmission.

2. When caring for an older incontinent client at risk for infection, which intervention is best for the nurse to implement based on the nursing diagnosis of risk for infection?

A. Maintain standard precautions.
B. Initiate contact isolation measures.
C. Insert an indwelling urinary catheter.
D. Instruct the client in the use of adult diapers.

Correct answer: A

Rationale: The correct intervention for an older incontinent client at risk for infection is to maintain standard precautions. Standard precautions, which include proper handwashing, are essential in reducing the risk of infection transmission in vulnerable clients. Initiating contact isolation measures may not be necessary for all clients, and inserting an indwelling urinary catheter should be avoided unless medically necessary to prevent additional risks of infection. Instructing the client in the use of adult diapers is not an appropriate nursing intervention to prevent infection.

3. The client is 5 feet from the bathroom door when he states, 'I feel faint.' Before the nurse can get the client to a chair, the client starts to fall. What is the priority action for the nurse to take?

A. Check the client's carotid pulse.
B. Encourage the client to get to the toilet.
C. In a loud voice, call for help.
D. Gently lower the client to the floor.

Correct answer: D

Rationale: The priority action for the nurse in this situation is to gently lower the client to the floor. This action helps prevent injury to both the client and the nurse. It is important to ensure a safe environment and protect the client from falling, as well as to maintain the nurse's own safety while providing care.

4. When making the bed of a client who needs a bed cradle, which action should the nurse include?

A. Teach the client to call for help before getting out of bed.
B. Keep both the upper and lower side rails in a raised position.
C. Keep the bed in the lowest position while changing the sheets.
D. Drape the top sheet and covers loosely over the bed cradle.

Correct answer: D

Rationale: A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top sheet and covers loosely over the cradle. This helps in maintaining the proper positioning and function of the bed cradle to ensure the client's comfort and safety during bed making.

5. The client has a chest tube. What is the most important action for the nurse to take?

A. Ensure the chest tube remains unclamped at all times.
B. Empty the chest tube every 2 hours.
C. Keep the drainage system below the level of the chest.
D. Assess for subcutaneous emphysema.

Correct answer: C

Rationale: Keeping the drainage system below the level of the chest (C) is crucial to ensure proper drainage and prevent backflow of air or fluid into the chest cavity. This position helps maintain the integrity of the closed drainage system. Ensuring the chest tube remains unclamped at all times (A) allows for continuous drainage. Emptying the chest tube (B) should be done as needed, not routinely every 2 hours. Assessing for subcutaneous emphysema (D) is important but not the most critical action in this scenario.

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