a nurse is preparing an infusion for a client who was hospitalized with deep vein thrombosis the orders read 25000 units of heparin in 250 ml of 09 so
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Nursing Elites

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HESI Fundamentals Exam Test Bank

1. A nurse is preparing an infusion for a client who was hospitalized with deep-vein thrombosis. The orders read: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump?

Correct answer: A

Rationale: To calculate the infusion rate, use the formula: (Desired units/hr / Total units) × Volume. In this case, it would be (800 units/hr / 25,000 units) × 250 mL = 8 mL/hr. Therefore, the nurse should set the infusion pump at 8 mL/hr. Choice B, 10 mL/hr, is incorrect because it does not match the calculated rate. Choices C and D, 12 mL/hr and 15 mL/hr respectively, are also incorrect as they do not align with the correct calculation based on the provided data.

2. A client requires a 24-hour urine collection. Which statement by the client indicates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C because for a 24-hour urine collection, the first void is discarded, and all subsequent urine should be saved. Choice A is incorrect because bowel movements do not contribute to a urine collection. Choice B indicates a single specimen rather than continuous collection over 24 hours. Choice D is incorrect as it incorrectly suggests rushing the test by drinking excessively.

3. During an assessment, a healthcare professional is evaluating the body alignment of a standing patient. Which finding will the healthcare professional report as normal?

Correct answer: A

Rationale: During a standing assessment, the healthcare professional should observe the patient laterally. In a normal body alignment, the head is erect, and the spinal curves align in a reversed 'S' pattern, aiding in maintaining balance and posture. Choice B is incorrect because hips and shoulders should be level and not form an 'S' pattern when observed posteriorly. Choice C is incorrect as the position of the arms is not a key indicator of body alignment. Choice D is incorrect as the feet should be shoulder-width apart with toes pointing forward for optimal balance and stability.

4. A client expresses that, based on religious values and mandates, a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make?

Correct answer: D

Rationale: The correct response is to involve the client's religious and spiritual leaders in the discussion to find a solution that respects both the client's values and medical needs. Option A is incorrect as it dismisses the client's beliefs. Option B assumes the family's opinion over the client's. Option C is inappropriate as it questions the client's religious beliefs rather than addressing the concern respectfully.

5. The healthcare provider is providing teaching to an immobilized patient with impaired skin integrity about diet. Which diet will the healthcare provider recommend?

Correct answer: A

Rationale: The correct answer is A: High protein, high calorie. An immobilized patient with impaired skin integrity requires a diet high in protein and calories to repair injured tissue and rebuild depleted protein stores. This helps in promoting wound healing and preventing further breakdown of the skin. Choices B, C, and D are incorrect because while vitamins and minerals are essential for overall health, in this case, the priority is on providing sufficient protein and calories to support healing and recovery in an immobilized patient with impaired skin integrity.

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