the uaps working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left sided weakness fr
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Nursing Elites

HESI RN

HESI Fundamentals Practice Test

1. The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client?

Correct answer: D

Rationale: The correct transfer procedure for an elderly client with left-sided weakness involves moving the chair parallel to the right side of the bed and standing the client on the right foot. Using the stronger side, the right side, for weight-bearing during the transfer is the safest approach to prevent falls or injuries. Placing the chair at a right angle to the bed on the client's left side before moving can lead to poor body mechanics and increase the risk of accidents. Assisting the client to a standing position and having the client pivot to the left are not recommended for a client with left-sided weakness as it can compromise safety and stability during the transfer.

2. The nursing staff in the cardiovascular intensive care unit is creating a continuous quality improvement project on social media that addresses coronary artery disease (CAD). Which action should the nurse implement to protect client privacy?

Correct answer: A

Rationale: To protect client privacy on social media, it is essential to remove any identifying information of clients who participated in the project. This ensures that sensitive information is not disclosed without consent and maintains confidentiality. Choice B is incorrect because while authored content may be legally discoverable, it does not directly relate to protecting client privacy on social media. Choice C is incorrect as it pertains to the credibility of sources, not client privacy. Choice D is also incorrect as it focuses on copyright laws rather than client privacy protection.

3. A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?

Correct answer: D

Rationale: The correct action for the nurse to take first in this situation is to compare the current blood pressure reading with the client's previously documented readings. This comparison will provide valuable information about what is normal for this specific client, helping to determine if the current reading represents a significant change or if it falls within the client's usual range. By reviewing the client's past readings, the nurse can assess trends, variations, and if the current reading is an isolated high value or part of a pattern, guiding appropriate decision-making. Informing the client about the high reading (Choice A) or contacting the healthcare provider for medication (Choice B) should come after assessing the client's history. Replacing the cuff (Choice C) is not necessary at this point and does not address the immediate need to compare the readings for appropriate intervention.

4. The charge nurse observes that a demographic screen has been left open on a hallway computer by a nurse who is responding to a call light while the unlicensed assistive personnel (UAP) is involved in a personal phone call. Which action should the charge nurse take first?

Correct answer: B

Rationale: The charge nurse's first action should be to close the demographic screen on the computer to protect patient confidentiality and prevent unauthorized access to sensitive information. This immediate response addresses the breach of patient privacy and ensures that patient data is secure, setting the right priority in managing the situation.

5. When assisting an older adult client in preparing to take a tub bath, which nursing action is most important?

Correct answer: A

Rationale: The most crucial nursing action when assisting an older adult client with a tub bath is to check the bath water temperature. This step is essential to prevent burns from hot water or chilling from water that is too cold. Ensuring the water temperature is safe is a critical aspect of promoting the client's safety and comfort during the bathing process.

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