a nurse enters a clients room and finds her on the floor the clients roommate reports that the client fell out of bewhich of the following statements
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HESI Fundamentals Practice Questions

1. A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client fell out of bed. Which of the following statements should the nurse document?

Correct answer: B

Rationale: The correct answer is B. The documentation should be clear and precise, providing details about the context of the fall. Choice A is vague and does not specify the cause of the client being on the floor. Choice C is less specific and does not directly state that the client fell from the bed. Choice D is wordy and less direct compared to option B, which clearly states that the client fell out of bed and was found on the floor.

2. A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct action for the nurse to take is to gently shake the container of liquid medication before administration. Shaking the container ensures proper mixing of the medication, which is important to maintain uniformity of the dose. Transferring the medication to a medicine cup (choice B) may not be necessary for a small volume like 0.5 mL. Placing the client in a semi-Fowler's position (choice C) is not directly related to administering liquid medication orally. Verifying the dosage by measuring the liquid (choice D) is important but does not address the specific action needed to prepare the medication for administration.

3. The nurse in the emergency department observes a colleague viewing the electronic health record (EHR) of a client who holds an elected position in the community. The client is not a part of the colleague's assignment. Which action should the nurse implement?

Correct answer: A

Rationale: Communicating the colleague's actions to the unit charge nurse is the most appropriate action to take in this scenario. Reporting to the charge nurse follows proper protocol and ensures privacy compliance. This option allows for addressing the issue internally within the healthcare setting, maintaining confidentiality, and following the chain of command. Sending an email to facility administration (Choice B) might be premature without internal investigation and could potentially bypass the immediate supervisor who is responsible for addressing such issues. Writing an anonymous complaint to a professional website (Choice C) and posting a comment about the action on a staff discussion board (Choice D) are not professional or effective ways to address the situation, as they do not ensure proper handling of the breach of privacy within the organization.

4. When teaching the guardian of a 12-year-old male client about manifestations of puberty, which of the following physical changes typically occurs first?

Correct answer: C

Rationale: During puberty in males, the first physical change that typically occurs is the enlargement of the testes and scrotum. This change is due to increased production of testosterone, which stimulates growth and development of the genital organs. The appearance of downy hair on the upper lip (Choice A) and hair growth in the axillae (Choice B) usually follow the enlargement of the testes and scrotum. Deepening of the voice (Choice D) is a later stage change that occurs during puberty as the larynx (voice box) grows and the vocal cords lengthen and thicken.

5. A client receives the influenza vaccine in a clinic. Within 15 minutes after the immunization, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. What should be the first action in the sequence of care for this client?

Correct answer: B

Rationale: In the scenario described, the client is experiencing symptoms of an anaphylactic reaction, a severe allergic response. The priority action in an anaphylactic reaction is to administer epinephrine. Epinephrine helps counteract the severe allergic response, improves breathing difficulties, and maintains airway and circulation. Administering epinephrine takes precedence to stabilize the client's condition. Options A, C, and D may be necessary in the management of anaphylaxis, but the immediate priority is to administer epinephrine to address the life-threatening symptoms.

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