what assessment finding places a client at risk for problems associated with impaired skin integrity
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Nursing Elites

HESI RN

HESI Fundamentals Practice Exam

1. What assessment finding places a client at risk for problems associated with impaired skin integrity?

Correct answer: B

Rationale: The correct answer is B. A capillary refill time greater than 3 seconds indicates poor perfusion, leading to impaired skin integrity. Delayed capillary refill can compromise blood flow to the skin, increasing the risk of pressure ulcers or wounds due to reduced tissue perfusion. Choices A, C, and D are incorrect because scattered macules on the face, smooth nail texture, and presence of skin tenting are not direct indicators of impaired skin integrity or risk for skin problems.

2. An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?

Correct answer: C

Rationale: The correct position for administering a soap suds enema is the Sims' position, not the left lateral position. The Sims' position allows the enema solution to follow the anatomical course of the intestines and provides the best overall results. By repositioning the client in the Sims' position, the weight is distributed to the anterior ilium, facilitating the enema administration process.

3. A client is admitted to the hospital with a diagnosis of pneumonia. Which laboratory test result should the nurse monitor to evaluate the client’s respiratory function?

Correct answer: A

Rationale: Arterial blood gases (ABGs) are the most appropriate laboratory test to monitor respiratory function in a client with pneumonia. ABGs provide valuable information on oxygenation status, acid-base balance, and how well the lungs are exchanging gases. This information helps in assessing the effectiveness of ventilation and oxygenation, guiding treatment decisions, and evaluating the overall respiratory status of the client.

4. 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?

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.

5. What information should the nurse offer a client who uses herbal therapies to supplement their diet and manage common ailments about the general use of herbal supplements?

Correct answer: C

Rationale: It is essential for clients using herbal therapies to obtain herbs from manufacturers with a history of quality control for their supplements. This recommendation is crucial because quality control processes help in maintaining the purity and effectiveness of the herbal supplements. Option A is incorrect as it provides a negative and inaccurate generalization about herbs. Option B is also incorrect as there is existing evidence on the safety and efficacy of certain herbal supplements. Option D is not the most relevant information to offer initially to a client seeking advice on the general use of herbal supplements.

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