Question

The nurse determines that a client's oxygen flow meter is set at 1.5 L/minute, the nasal cannula is in place in the client's nares, and the oxygen tubing is disconnected from the flow meter. Which action would the nurse implement?

Answer 1

Correct Answers:

Connect the tubing to the flow meter.

Rationale :

💁‍♂️The disconnected oxygen tubing prevents the prescribed oxygen from reaching the client through the nasal cannula.

🔗Connecting the tubing to the flow meter immediately restores the ordered oxygen delivery system.

💨The prescribed 1.5 L/minute flow rate should remain unchanged unless a new prescription or clinical indication requires adjustment.

🩺Correcting the obvious equipment problem takes priority before performing additional respiratory assessment when the cause of interrupted oxygen delivery is known.

📌Core Message

Restoring the disconnected oxygen tubing to the flow meter immediately reestablishes the prescribed oxygen delivery to the client.

Answer 2

Correct Answers:

Time the bottle was opened.
Date opened.
Nurse's initials.

Rationale :

🧴An opened sterile irrigation solution should be marked with the time opened because sterility is affected after the container is opened.

📅The date opened provides essential information for determining how long the solution has been available for use.

✍️The nurse's initials identify the healthcare professional responsible for opening and labeling the solution.

🛡️Proper labeling practices promote infection prevention, accountability, and safe use of sterile solutions in the perioperative environment.

📌Core Message

An opened sterile irrigation bottle should be labeled with the date opened, time opened, and nurse's initials to support sterility monitoring and accountability.

Answer 3

Correct Answers:

Involve and educate clients in medication administration
Question unusually large or small doses
Use at least 2 client identifiers before administering a dose
Do not allow other activity to interrupt medication administration

Rationale :

💊Active client participation can provide an additional safety check because clients may recognize that a medication or dose differs from their usual therapy.

⚠️Questioning an unusually large dose could have identified that 800 mg differed substantially from the prescribed 300 mg dose.

💁‍♂️Using at least two client identifiers immediately before administration helps prevent wrong-client medication errors after interruptions or room changes.

🔕Reducing medication-administration interruptions decreases loss of concentration and lowers the risk of selecting or administering the wrong medication.

🛡️Together these medication-safety practices address the major factors involved in this error, including interruption, incorrect dose, and incorrect client identification.

📌Core Message

Effective medication-error prevention uses client participation, dose verification, two identifiers, and interruption control before medication administration.

Answer 4

Correct Answers:

Release the air and reinflate the cuff to 30 mm Hg above the client's previous systolic reading.

Rationale :

🩺Hearing Korotkoff sounds immediately after beginning cuff deflation indicates that the cuff was not inflated sufficiently above the client's actual systolic pressure.

🎈The nurse should completely deflate the cuff before repeating the measurement to avoid obtaining an inaccurate blood pressure.

📏Inflating approximately 30 mm Hg above the systolic pressure ensures that the brachial artery is fully occluded before controlled deflation begins.

❤️This technique allows accurate identification of the first Korotkoff sound, which represents the systolic blood pressure.

📌Core Message

Immediate Korotkoff sounds indicate inadequate cuff inflation, requiring deflation followed by reinflation approximately 30 mm Hg above systolic pressure.

Answer 5

Correct Answers:

0.5

Rationale :

💊The prescribed dose is 8 mg, while each available tablet contains 16 mg of candesartan cilexetil.

👉The calculation is 8 mg ÷ 16 mg/tablet, which produces 0.5 tablet.

📐The calculated amount is already expressed to the requested nearest tenth as 0.5.

💪Administering one-half tablet supplies the client's prescribed 8 mg dose.

📌Core Message

A prescribed 8 mg dose supplied as 16 mg per tablet requires one-half of the available tablet.

Answer 6

Correct Answers:

Starts at wound site and moves outward using circular motions.

Rationale :

🩹Wound cleansing should generally progress from the least contaminated area toward the more contaminated surrounding skin.

🌀Beginning at the wound and moving outward in circular motions prevents microorganisms from being carried from surrounding skin back into the cleaner wound area.

🧼Each cleansing stroke should use a fresh sterile portion of the gauze or applicator to prevent recontamination.

🛡️This clean-to-dirty technique supports infection prevention and protects healing tissue from unnecessary contamination.

📌Core Message

Proper wound cleansing proceeds from the cleaner wound area outward toward more contaminated surrounding tissue to reduce infection risk.

Answer 7

Correct Answers:

A private room with both contact and airborne precautions.

Rationale :

🦠Varicella-zoster virus can spread through airborne respiratory particles and through direct contact with fluid from skin lesions.

🌬️Airborne precautions require placement in an airborne infection isolation room with appropriate respiratory protection when available.

🧤Contact precautions are also necessary because infectious material is present within the client's vesicular lesions.

🚪A private room helps prevent transmission to susceptible clients and healthcare personnel.

📌Core Message

Active varicella infection requires a private room with both airborne precautions and contact precautions because transmission occurs through respiratory particles and lesion fluid.

Answer 8

Correct Answers:

Offer mouth care before and after every meal.

Rationale :

👄Chemotherapy can cause oral mucositis, producing painful inflammation and ulceration of the oral mucosa.

💁‍♂️Frequent gentle mouth care removes debris, limits bacterial growth, and promotes comfort without unnecessarily traumatizing oral tissues.

🍽️Providing mouth care before and after meals can improve comfort during eating and maintain oral cleanliness afterward.

💧Appropriate oral care should use nonirritating solutions and a soft toothbrush when tolerated to protect fragile mucosal tissue.

📌Core Message

Frequent gentle mouth care before and after meals reduces discomfort and promotes oral integrity in clients experiencing chemotherapy-induced mucositis.

Answer 9

Correct Answers:

Using the syringe to remove the specimen from the catheter.

Rationale :

🧤Gloves are required when there is potential contact with urine, which is treated as a body fluid under standard precautions.

💉Aspirating the specimen from the catheter's sampling port places the nurse closest to potential exposure to urine.

🧫Once the specimen container is securely enclosed within a biohazard bag, routine external transport does not require gloves if the outside of the bag is uncontaminated.

🛡️Using standard precautions appropriately reduces occupational exposure while preventing unnecessary contamination of environmental surfaces.

📌Core Message

Gloves are required during urine specimen aspiration because this step creates the greatest potential for direct contact with a client's body fluid.

Answer 10

Correct Answers:

Fits the crutch 2 finger widths from axilla.

Rationale :

👉Properly fitted crutches should leave approximately two to three finger widths between the axilla and the top of the crutch.

💪The client's weight should be supported through the hands and arms rather than through the axillae.

⚡Excessive pressure in the axillary region can injure the brachial plexus and impair circulation.

📏Correct crutch fitting improves balance, mobility, and safety while decreasing the risk of nerve compression.

📌Core Message

Proper crutch fitting maintains approximately two to three finger widths of axillary clearance so body weight is supported through the hands rather than the axillae.

HESI RN Fundamentals Exam-1

No.

1 :
The nurse determines that a client's oxygen flow meter is set at 1.5 L/minute, the nasal cannula is in place in the client's nares, and the oxygen tubing is disconnected from the flow meter. Which action would the nurse implement?

2 :
The perioperative nurse is preparing the supplies for a surgery. After opening a sterile bottle of saline for irrigation, how should the nurse label the opened bottle? Select all that apply.

3 :
The client's nurse went into a room to administer a dose of clindamycin. The nurse was paged for a rapid response in the unit before they could administer the dose.

Answer Options

4 :
While assessing a client's blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm Hg. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. Which action should the nurse implement next?

5 :
A client with hypertension has a prescription for 8 mg of candesartan cilexetil PO daily. The medication is available in a 16 mg tablet. How many tablets should the nurse administer? (Enter numeric value only, rounded to the tenth.)

6 :
The charge nurse is observing a new graduate's performance of wound care. Which technique indicates that the employee is effectively cleansing the wound?

7 :
A client is being admitted to the unit with a varicella zoster virus infection. Which room should the charge nurse assign to the client?

8 :
A client undergoing chemotherapy has developed painful mouth sores. Which intervention should the nurse include in the plan of care to reduce the client's discomfort?

9 :
The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear glove?

10 :
The nurse is teaching a client how to use crutches. Which action performed by the client demonstrates to the nurse a correct understanding of how to use the crutches?

HESI RN Fundamentals Exam-1

No.

1 : The nurse determines that a client's oxygen flow meter is set at 1.5 L/minute, the nasal cannula is in place in the client's nares, and the oxygen tubing is disconnected from the flow meter. Which action would the nurse implement?

2 : The perioperative nurse is preparing the supplies for a surgery. After opening a sterile bottle of saline for irrigation, how should the nurse label the opened bottle? Select all that apply.

3 : The client's nurse went into a room to administer a dose of clindamycin. The nurse was paged for a rapid response in the unit before they could administer the dose.

Answer Options

4 : While assessing a client's blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm Hg. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. Which action should the nurse implement next?

5 : A client with hypertension has a prescription for 8 mg of candesartan cilexetil PO daily. The medication is available in a 16 mg tablet. How many tablets should the nurse administer? (Enter numeric value only, rounded to the tenth.)

6 : The charge nurse is observing a new graduate's performance of wound care. Which technique indicates that the employee is effectively cleansing the wound?

7 : A client is being admitted to the unit with a varicella zoster virus infection. Which room should the charge nurse assign to the client?

8 : A client undergoing chemotherapy has developed painful mouth sores. Which intervention should the nurse include in the plan of care to reduce the client's discomfort?

9 : The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear glove?

10 : The nurse is teaching a client how to use crutches. Which action performed by the client demonstrates to the nurse a correct understanding of how to use the crutches?

1 :
The nurse determines that a client's oxygen flow meter is set at 1.5 L/minute, the nasal cannula is in place in the client's nares, and the oxygen tubing is disconnected from the flow meter. Which action would the nurse implement?

2 :
The perioperative nurse is preparing the supplies for a surgery. After opening a sterile bottle of saline for irrigation, how should the nurse label the opened bottle? Select all that apply.

3 :
The client's nurse went into a room to administer a dose of clindamycin. The nurse was paged for a rapid response in the unit before they could administer the dose.

4 :
While assessing a client's blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm Hg. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. Which action should the nurse implement next?

5 :
A client with hypertension has a prescription for 8 mg of candesartan cilexetil PO daily. The medication is available in a 16 mg tablet. How many tablets should the nurse administer? (Enter numeric value only, rounded to the tenth.)

6 :
The charge nurse is observing a new graduate's performance of wound care. Which technique indicates that the employee is effectively cleansing the wound?

7 :
A client is being admitted to the unit with a varicella zoster virus infection. Which room should the charge nurse assign to the client?

8 :
A client undergoing chemotherapy has developed painful mouth sores. Which intervention should the nurse include in the plan of care to reduce the client's discomfort?

9 :
The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear glove?

10 :
The nurse is teaching a client how to use crutches. Which action performed by the client demonstrates to the nurse a correct understanding of how to use the crutches?