a charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses which of the following examples should the nurse i
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HESI Fundamentals Exam Test Bank

1. A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the nurse include as a developmental task for middle adulthood?

Correct answer: D

Rationale: The correct answer is D because in middle adulthood, individuals often shift their focus towards concerns related to the next generations. They reflect on their roles in guiding and supporting the younger generations. Choice A is incorrect as evaluating behavior after a social interaction is more relevant to self-awareness, which is not a specific developmental task for middle adulthood. Choice B, learning to trust others, is more commonly associated with early adulthood tasks related to forming intimate relationships. Choice C, wishing to find meaningful friendships, is more aligned with tasks associated with young adulthood and social connections.

2. An assistive personnel says to the nurse, “This client is incontinent of stool three or four times a day. I get angry, and I think that the client is doing it just to get attention. I think we should put adult diapers on her.” Which is the appropriate nursing response?

Correct answer: B

Rationale: The correct response is 'It is very upsetting to see an adult client regress.' In this situation, the nurse should acknowledge the emotional impact of caregiving on the assistive personnel and address it professionally. Choice A is incorrect because reporting to the supervisor may not directly address the emotional concerns raised. Choice C is incorrect because immediately resorting to diapers without further assessment or intervention is not the most appropriate solution. Choice D is incorrect as the client's well-being and care are a shared responsibility among healthcare team members.

3. When admitting a client with an abdominal wound, which precaution should be taken?

Correct answer: A

Rationale: When admitting a client with an abdominal wound, contact precautions should be implemented. Contact precautions are used to prevent the spread of infections that are spread by direct or indirect contact. In the case of abdominal wounds, bacteria and pathogens can easily be transmitted through contact with the wound or wound drainage. Droplet precautions are used for infections transmitted through respiratory droplets, such as influenza. Airborne precautions are used for infections spread through the air, like tuberculosis. Standard precautions are used for all clients to prevent the spread of infections and should be followed in addition to specific precautions based on the type of infection.

4. A client who is 3 days post-op following a cholecystectomy has yellow and thick drainage on the dressing. The nurse suspects a wound infection. The nurse identifies this type of drainage as:

Correct answer: A

Rationale: The correct answer is A: Purulent. Purulent drainage is thick, yellow, and indicates the presence of infection. This type of drainage is typically seen in infected wounds. Choice B, Serous drainage, is thin, clear, and watery, which is normal in the initial stages of wound healing. Sanguineous drainage, choice C, is bright red and indicates fresh bleeding. Serosanguineous drainage, choice D, is pale pink to red and is a mixture of blood and serous fluid commonly seen in the early stages of wound healing.

5. During a skin assessment, a healthcare professional is observing a group of clients. Which of the following lesions should the healthcare professional identify as vesicles?

Correct answer: D

Rationale: Vesicles are small fluid-filled blisters. Herpes simplex is an example of a vesicular lesion, characterized by small, fluid-filled blisters. Acne presents as comedones, papules, pustules, or nodules, not vesicles. Warts are caused by the human papillomavirus and appear as rough, raised growths. Psoriasis is a chronic autoimmune condition that results in red, scaly patches on the skin, not vesicles.

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