Question

The nurse is planning to provide mouth care for an unconscious client. Which statement is accurate in regard to implementing mouth care for this client?

Answer 1

Correct Answers:

Positioning the unconscious client with the head turned to the side is the key to providing safety during mouth care.

Rationale :

💧Positioning the unconscious client on the side allows oral secretions to drain from the mouth instead of being aspirated into the lungs.

💨This side-lying position helps maintain a clear airway by using gravity to prevent pooling of fluids or cleaning agents in the oropharynx.

🧼Aspiration pneumonia is a major risk for unconscious clients, and proper positioning is a primary safety measure before any oral care is performed.

🩺This demonstrates nursing prioritization of airway maintenance, which aligns with the ABC principle (Airway, Breathing, Circulation) and reinforces that safety always comes before hygiene in unconscious care.

📌Core message

Maintain a side-lying position during mouth care to prevent aspiration and protect the airway.

Answer 2

Correct Answers:

Place the pulse oximeter on the client's earlobe.

Rationale :

💡An earlobe probe is used when finger readings are unreliable due to factors such as poor perfusion, cold extremities, or nail polish.

🩺The earlobe and forehead often provide more accurate oxygen saturation readings because they are less affected by peripheral vasoconstriction.

🧾Ensuring an accurate reading is essential before initiating or changing oxygen therapy, as incorrect data can lead to inappropriate treatment.

⚕️By verifying with a different site, the nurse ensures safe, evidence-based care and adheres to the nursing process of validation before intervention.

📌Core message

Verify low oxygen readings by using alternative probe sites like the earlobe before making clinical decisions.

Answer 3

Correct Answers:

Retake vital signs
Assess the client

Rationale :

🩺Assessment and confirmation are the first steps when abnormal findings are reported, as machine or human error is possible.

💡Retaking vital signs ensures accuracy and provides a reliable baseline for appropriate interventions.

📋Assessing the client’s condition helps identify symptoms such as headache, dizziness, or chest pain, which may indicate hypertensive urgency.

⚕️These actions align with the nursing process, which prioritizes assessment before implementation or notification of the provider.

📌Core message

Begin with reassessment and client evaluation before implementing interventions for abnormal vital signs.

Answer 4

Correct Answers:

Open the sterile field facing the body.
Leave the sterile field to gather additional supplies.

Rationale :

🧼Opening a sterile field toward the body risks contamination from the nurse’s clothing, breaking sterile technique.

🧍‍♀️Leaving the sterile field unattended allows for airborne or accidental contamination because sterility cannot be maintained without constant supervision.

💡A sterile field must remain in sight and above waist level to ensure it stays uncontaminated.

⚕️Maintaining aseptic technique is essential to preventing infection and promoting client safety during invasive procedures.

📌Core message

Never turn your back or face the sterile field toward your body—maintain constant visual supervision for sterility.

Answer 5

Correct Answers:

Call the HCP to return and provide additional explanation.

Rationale :

📜Only the provider who obtains informed consent can clarify details about a procedure’s risks, benefits, and purpose.

💬The nurse’s role is to witness the signature and verify understanding, not to explain medical procedures in detail.

🩺By contacting the HCP, the nurse ensures the client makes an informed and voluntary decision.

⚕️This action upholds legal and ethical standards for informed consent and protects client autonomy.

📌Core message

If the client has questions about a procedure, the provider must clarify before consent is valid.

Answer 6

Correct Answers:

Ask the client for a description of the exercise schedule that is being followed.

Rationale :

🩺The nurse must assess patterns and timing of activity before giving advice, as exercising close to bedtime can cause insomnia.

💬Assessment before intervention is a key principle of the nursing process to determine contributing factors.

🧘‍♀️High-intensity workouts late in the day may increase adrenaline and heart rate, making sleep difficult.

⚕️Gathering data on the exercise schedule allows the nurse to individualize recommendations for lifestyle modification.

📌Core message

Always assess exercise timing and patterns before advising clients with sleep disturbances.

Answer 7

Correct Answers:

0.8

Rationale :

📏To calculate, use the formula: Dose ordered ÷ Dose on hand × Volume available = Volume to administer.

🧮(8,200 ÷ 10,000) × 1 mL = 0.82 mL, which rounds to 0.8 mL.

💉This ensures the client receives the prescribed dose accurately, preventing under- or overdosing.

⚕️Precise medication calculation and rounding to the nearest tenth are essential in safe drug administration practices.

📌Core message

Accurate dose calculation and rounding are vital to ensure safe medication administration.

Answer 8

Correct Answers:

Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client.

Rationale :

😷Droplet precautions require a surgical mask, not a particulate respirator, because influenza spreads through large respiratory droplets.

💨A particulate filter mask (N95) is only needed for airborne precautions, such as tuberculosis or measles.

🩺Allowing the UAP to proceed with a standard face mask ensures appropriate infection control without unnecessary delay in care.

⚕️This response shows understanding of transmission-based precautions and appropriate PPE selection.

📌Core message

For droplet precautions, a surgical mask provides adequate protection; N95 masks are only for airborne infections.

Answer 9

Correct Answers:

The healthcare provider must project that the client has 6 months or less to live.
A client must be willing to accept palliative care, not curative care.

Rationale :

💐Hospice care is for clients with a terminal illness and a life expectancy of six months or less, as certified by a healthcare provider.

💊The focus of hospice is comfort and symptom relief (palliative care) rather than curative treatment.

📋Eligibility requires client consent and willingness to forego curative measures in exchange for quality of life support.

⚕️This ensures care aligns with end-of-life goals and the client’s autonomy and comfort.

📌Core message

Hospice care is for clients with ≤6 months prognosis who choose palliative over curative treatment.

Answer 10

Correct Answers:

Position the client supine for a few minutes.

Rationale :

🛏️Orthostatic (postural) hypotension assessment requires a baseline BP while the client is lying down.

🩺This position ensures the circulatory system is stabilized before changes in posture occur.

🪑Subsequent readings are taken after sitting and standing to evaluate for drops in BP ≥20 mmHg systolic or ≥10 mmHg diastolic.

⚕️Following the correct sequence ensures accurate data and protects the client from dizziness or fainting.

📌Core message

Begin orthostatic BP measurement with the client lying supine to obtain an accurate baseline reading.

HESI RN Fundamentals BSN 225

No.

1 :
The nurse is planning to provide mouth care for an unconscious client. Which statement is accurate in regard to implementing mouth care for this client?

📌Core message

📌Core message

3 :
The client is a 48-year-old male in the hospital for cellulitis to the left leg. He will receive IV antibiotics for the next 7 days. The client takes an angiotensin converting enzyme (ACE) inhibitor to control chronic-hypertension, which will also be continued in the hospital.

Answer Options

📌Core message

4 :
When preparing a sterile field, which action(s) by the nurse would compromise the sterility? Select all that apply.

📌Core message

📌Core message

6 :
A client tells the nurse about doing a high intensity workout program to help with losing weight but now describes having difficulty getting to sleep at night. Which action should the nurse implement?

📌Core message

📌Core message

8 :
The nurse has assigned an unlicensed assistive personnel (UAP) to assist bathing a client who has influenza and is on droplet precautions. The UAP requests a change in assignment, informing that she has not yet been fitted for a particulate mask. Which action should the nurse take?

📌Core message

9 :
A family member of a frail older adult asks the nurse about eligibility requirements for hospice care. Which information should the nurse provide? Select all that apply.

📌Core message

10 :
When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?

📌Core message

HESI RN Fundamentals BSN 225

No.

1 : The nurse is planning to provide mouth care for an unconscious client. Which statement is accurate in regard to implementing mouth care for this client?

📌Core message

📌Core message

3 : The client is a 48-year-old male in the hospital for cellulitis to the left leg. He will receive IV antibiotics for the next 7 days. The client takes an angiotensin converting enzyme (ACE) inhibitor to control chronic-hypertension, which will also be continued in the hospital.

Answer Options

📌Core message

4 : When preparing a sterile field, which action(s) by the nurse would compromise the sterility? Select all that apply.

📌Core message

📌Core message

6 : A client tells the nurse about doing a high intensity workout program to help with losing weight but now describes having difficulty getting to sleep at night. Which action should the nurse implement?

📌Core message

📌Core message

8 : The nurse has assigned an unlicensed assistive personnel (UAP) to assist bathing a client who has influenza and is on droplet precautions. The UAP requests a change in assignment, informing that she has not yet been fitted for a particulate mask. Which action should the nurse take?

📌Core message

9 : A family member of a frail older adult asks the nurse about eligibility requirements for hospice care. Which information should the nurse provide? Select all that apply.

📌Core message

10 : When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?

📌Core message

1 :
The nurse is planning to provide mouth care for an unconscious client. Which statement is accurate in regard to implementing mouth care for this client?

3 :
The client is a 48-year-old male in the hospital for cellulitis to the left leg. He will receive IV antibiotics for the next 7 days. The client takes an angiotensin converting enzyme (ACE) inhibitor to control chronic-hypertension, which will also be continued in the hospital.

4 :
When preparing a sterile field, which action(s) by the nurse would compromise the sterility? Select all that apply.

6 :
A client tells the nurse about doing a high intensity workout program to help with losing weight but now describes having difficulty getting to sleep at night. Which action should the nurse implement?

8 :
The nurse has assigned an unlicensed assistive personnel (UAP) to assist bathing a client who has influenza and is on droplet precautions. The UAP requests a change in assignment, informing that she has not yet been fitted for a particulate mask. Which action should the nurse take?

9 :
A family member of a frail older adult asks the nurse about eligibility requirements for hospice care. Which information should the nurse provide? Select all that apply.

10 :
When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?