nurse is preparing an education program for staff about advocacy what information should the nurse include
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Nursing Elites

HESI LPN

Fundamentals of Nursing HESI

1. A nurse is preparing an education program for staff about advocacy. What information should the nurse include?

Correct answer: A

Rationale: The correct answer is A. Advocacy in nursing involves ensuring clients' safety, health, and rights. Nurses advocate for their clients by promoting autonomy, informed decision-making, and protecting their rights. Choice B is incorrect because advocacy goes beyond just supporting client complaints; it encompasses a broader scope of ensuring holistic care and well-being. Choice C is incorrect as advocacy does not mean making all decisions for the client but rather empowering them to make informed choices. Choice D is incorrect as advocacy is a crucial component of nursing responsibilities, as it involves standing up for clients' best interests and ensuring their rights are respected.

2. A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing techniques?

Correct answer: A

Rationale: Proper surgical hand-washing technique involves keeping the hands higher than the elbows to prevent contamination. Washing with hands held lower than the elbows can lead to potential contamination. Using a brush to scrub under the nails is not recommended as it can cause microabrasions, increasing infection risk. While washing for at least 30 seconds is a good practice for thorough hand hygiene, hand positioning is critical during surgical hand-washing. Using alcohol-based hand rub alone is insufficient for surgical hand-washing as it may not effectively remove dirt, debris, and transient microorganisms.

3. The healthcare provider is caring for a client with tuberculosis (TB). Which type of isolation precautions should the healthcare provider implement?

Correct answer: B

Rationale: When caring for a client with tuberculosis (TB), airborne precautions should be implemented. Tuberculosis is spread through the air via droplet nuclei, requiring the use of airborne precautions to prevent the transmission of the infection. Droplet precautions are used for diseases spread by large respiratory droplets, such as influenza or pertussis. Contact precautions are used for diseases that spread through direct contact, such as MRSA. Standard precautions are used for all clients to prevent the transmission of infections from blood, body fluids, non-intact skin, and mucous membranes.

4. In planning care for a premature infant with respiratory distress syndrome, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to

Correct answer: B

Rationale: The correct answer is B: Maintain alveolar surface tension. Respiratory distress syndrome in premature infants is often caused by a deficiency in surfactant, a substance that helps maintain alveolar surface tension. Without adequate surfactant, the alveoli collapse, making it difficult for the infant to oxygenate effectively. Choices A, C, and D are incorrect because stabilizing alveolar surface tension is not the issue, promoting normal pulmonary blood flow and regulating intra-cardiac pressure are not directly related to the pathophysiology of respiratory distress syndrome in premature infants.

5. Which serum blood finding in diabetic ketoacidosis alerts the nurse that immediate action is required?

Correct answer: C

Rationale: A hematocrit (HCT) of 60 indicates severe dehydration, a critical condition in diabetic ketoacidosis that requires immediate intervention. Severe dehydration can lead to hypovolemic shock and organ failure. While a low pH below 7.3 is indicative of acidosis, it may not require immediate action compared to severe dehydration. A potassium level of 5.0 is within the normal range and not a critical finding in this scenario. PaO2 of 79% reflects oxygenation status, which is important but not the most critical finding requiring immediate action in diabetic ketoacidosis.

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