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. When assessing for orthostatic hypotension during blood pressure measurement, what action should the nurse implement first?

Correct answer: A

Rationale: When assessing for orthostatic hypotension, the initial step is to position the client supine for a few minutes. This allows the body to adjust to the supine position before assessing blood pressure changes that may indicate orthostatic hypotension. By observing the blood pressure after the client has rested supine, the nurse can accurately assess for any drop in blood pressure upon standing, which is indicative of orthostatic hypotension. Choices B, C, and D are incorrect as they do not address the initial step in assessing for orthostatic hypotension, which is ensuring the client is positioned correctly to detect blood pressure changes upon standing.

3. The healthcare provider is teaching a client with hypertension about lifestyle modifications. Which instruction should the healthcare provider include?

Correct answer: B

Rationale: Engaging in moderate exercise for 30 minutes daily is a crucial lifestyle modification for managing hypertension. Regular physical activity helps lower blood pressure, improve cardiovascular health, and overall well-being. It is recommended to engage in activities like brisk walking, cycling, or swimming to achieve these benefits. Choices A, C, and D are incorrect. Limiting sodium intake, avoiding a diet high in saturated fats, and reducing alcohol consumption are also important lifestyle modifications for hypertension management, but engaging in moderate exercise is the most appropriate initial instruction for this client.

4. When a student nurse is caught taking a copy of a client's medication administration record to help a friend prepare for the next day's clinical, what should the nurse respond first?

Correct answer: D

Rationale: The correct response when a student nurse is caught taking a copy of a client's medication administration record is to explain that the records are hospital property and cannot be removed. It is essential to educate the student about the confidentiality and security of patient information, emphasizing that even with the client's consent, such actions are unacceptable. Option A is not the immediate action needed, as addressing the student directly should come first. Option B involves notifying another party before addressing the student directly. Option C is incorrect because even if the client gave permission, patient records are confidential and cannot be shared without authorization.

5. 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.

Similar Questions

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