the nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous iv access is an antecubital saline lock after the n
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Nursing Elites

HESI RN

HESI Fundamentals Practice Exam

1. The healthcare professional is administering an intermittent infusion of an antibiotic to a client with an antecubital saline lock. After opening the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should be taken first?

Correct answer: B

Rationale: Repositioning the client's arm is the initial action to take when encountering an obstruction with an antecubital saline lock. Repositioning may correct any bending at the elbow that could be causing the obstruction, allowing for smoother infusion flow. Checking for a blood return, removing the IV site dressing, or flushing the lock with saline would be subsequent actions once the obstruction is addressed. Checking for a blood return is done to confirm proper placement, removing the IV site dressing is necessary for site assessment, and flushing the lock with saline helps maintain patency but should not be the first action when an obstruction is detected.

2. The client is being instructed on the proper use of a metered-dose inhaler. Which instruction should be provided to ensure the optimal benefits from the drug?

Correct answer: B

Rationale: The correct technique for using a metered-dose inhaler involves compressing the inhaler while slowly breathing in through the mouth. This method helps ensure that the medication reaches deep into the lungs, allowing for optimal bronchodilation effect. Inhaling quickly through the nose or filling the lungs with air before compressing the inhaler are not recommended techniques for using a metered-dose inhaler effectively.

3. While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement?

Correct answer: A

Rationale: The wife is correctly performing the passive range-of-motion exercises by holding the arm above and below the elbow. The nurse should acknowledge this correct technique (A). It is essential to keep the joint uncovered (B) during exercises, while ensuring the rest of the body remains covered for warmth and privacy. Choices (C) and (D) do not provide optimal support to the joint for effective movement.

4. A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide?

Correct answer: A

Rationale: The correct instruction for the nurse to provide is to advise the client to decrease intake of fluids after the evening meal. By reducing fluid intake before bedtime, the client can minimize the need to void during the night, which can help improve sleep patterns affected by nocturia. Choices B, C, and D are incorrect. Drinking cranberry juice or warm decaffeinated beverage at bedtime may increase fluid intake, exacerbating the nocturia issue. Consulting the healthcare provider about a sleeping pill should not be the first intervention, as it is important to try non-pharmacological approaches first.

5. A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend first?

Correct answer: C

Rationale: Keeping a food diary is a good first step to understand eating habits before making any dietary or activity changes.

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