HESI Fundamentals

Correct Answer:Acknowledge that she is supporting the arm correctly.

Explanation:

This is the correct answer because the proper technique for performing passive range-of-motion (ROM) exercises involves supporting the limb above and below the joint being moved. This prevents stress on the joint, reduces discomfort, and allows for smooth movement through the range of motion. In the case of the contracted shoulder, supporting the arm above and below the elbow ensures joint stability and prevents injury. Positive reinforcement encourages the caregiver to continue performing the exercises correctly.

Why the Other Options Are Incorrect:

Encourage her to keep the joint covered to maintain warmth:

This is incorrect because while warmth can increase circulation and flexibility, it is not essential during passive ROM exercises. The primary focus is on performing the exercises correctly to prevent further contractures and improve mobility. The position of her hands is more critical for effective and safe movement.

Reinforce the need to grip directly under the joint for better support:

This is incorrect because gripping directly under the joint could stress the shoulder and does not provide the optimal support needed for smooth movement. Supporting above and below the joint distributes the weight and pressure more effectively, minimizing the risk of pain or injury.

 Instruct her to grip directly over the joint for better motion:

This is incorrect because gripping over the joint can restrict movement and cause discomfort. Additionally, this method does not stabilize the limb effectively during passive ROM. The correct technique involves holding the limb above and below the joint to allow full, controlled motion without causing harm.

Summary:

The correct action is to acknowledge that the client’s wife is supporting the arm correctly by holding it above and below the elbow. This method stabilizes the shoulder, reduces stress on the joint, and facilitates safe and effective passive range-of-motion exercises. The other options are incorrect because they either provide inadequate support, restrict motion, or focus on non-essential aspects rather than the correct technique.

Correct Answer: Decrease intake of fluids after the evening meal.

This instruction is the most important because reducing fluid intake in the evening can help minimize the frequency of nocturia (waking up at night to urinate). Nocturia disrupts sleep patterns, leading to daytime fatigue, impaired concentration, and reduced quality of life. By encouraging the client to limit fluids—especially diuretics like caffeine and alcohol—in the hours leading up to bedtime, the nurse can reduce nighttime urination and improve sleep quality

Why the other options are incorrect:

Drink a glass of cranberry juice every day

Although cranberry juice may help prevent urinary tract infections by reducing bacterial adhesion to the bladder wall, it does not address the primary issue of nocturia. Furthermore, consuming fluids before bedtime increases the likelihood of nighttime urination, worsening the problem.

 Drink a glass of warm decaffeinated beverage at bedtime

Although decaffeinated beverages do not stimulate the bladder as caffeine does, any fluid intake before bedtime can still contribute to nocturia. This recommendation is counterproductive because it would increase bladder filling during the night.

 Consult the health care provider about a sleeping pill

While sleeping pills might help the client fall asleep, they do not address the underlying cause of nocturia. Additionally, sleep aids can have side effects such as daytime drowsiness, confusion, and an increased fall risk, particularly in older adults. The first-line approach should focus on behavioral modifications, like adjusting fluid intake.

Summary:

The most effective and safest intervention for a client with altered sleep patterns due to nocturia is to decrease fluid intake after the evening meal. This prevents excessive bladder filling, reduces nighttime awakenings, and improves sleep quality without introducing medication-related risks or worsening symptoms through unnecessary fluid consumption.

Correct Answer: Standing on his wife's weak side, the caregiver provides security by holding the gait belt from the back.

This is the correct choice because standing on the weak side allows the caregiver to provide immediate support where the client is most vulnerable. Individuals with one-sided weakness are at increased risk of falling on their affected side due to muscle weakness, poor balance, or coordination issues. By positioning themselves on the weak side, the caregiver can respond quickly if the client starts to lose balance or experiences fatigue. Holding the gait belt from the back ensures that the caregiver has a firm grip while allowing the client to move naturally. This technique also provides stability without restricting the client's movement. The grip should be secure but not tight to prevent discomfort while still allowing the caregiver to control the client's movements in case of unsteadiness. This method is widely recommended by healthcare professionals because it balances safety, support, and client autonomy during ambulation.

Why the other options are incorrect:

Standing on his wife's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed.

This option is incorrect because supporting the strong side does not provide the necessary assistance where it is most needed. If the client loses balance, it is more likely to occur on the weak side, leaving the caregiver in a poor position to prevent a fall. While it may seem logical to protect the stronger side, it neglects the more vulnerable side, which requires closer monitoring. Additionally, if the caregiver is on the strong side, they may not be able to react quickly if the client collapses or begins to fall toward their weak side.

Standing behind his wife, the caregiver provides balance by holding both sides of the gait belt.

This option is incorrect because standing directly behind the client reduces visibility and limits the caregiver's ability to observe facial expressions or subtle signs of distress. If the client stumbles, the caregiver cannot react swiftly to prevent a fall. Additionally, this position provides limited lateral support, making it difficult to stabilize the client if they sway to either side. It also compromises body mechanics for the caregiver, increasing the risk of injury to both the caregiver and the client.

Standing slightly in front and to the right of his wife, the caregiver guides her forward by gently pulling on the gait belt

This option is incorrect because pulling the client forward is unsafe and can disrupt the client's natural gait. It also increases the risk of forward falls if the client loses their footing. Moreover, standing in front prevents the caregiver from catching the client if they start to fall backward or to the side. This approach does not offer the supportive and responsive positioning needed for a client with unilateral weakness. Proper ambulation assistance requires the caregiver to be behind and slightly to the weak side for optimal balance and safety.

Summary:

The best approach when assisting someone with a gait belt is for the caregiver to stand on the weak side while holding the gait belt from the back. This positioning allows the caregiver to provide immediate support where it is needed most, observe changes in the client's stability, and prevent falls more effectively. The other options are incorrect because they either fail to offer adequate support, restrict the caregiver's ability to react swiftly, or introduce unsafe practices that increase the risk of injury for both the client and the caregiver.

Correct Answer:  Observe the appearance of the skin under the ice pack.

Explanation:

The nurse’s first action should be to assess the skin under the ice pack to ensure there is no frostbite, tissue damage, or other adverse effects from direct contact with ice. Prolonged or direct exposure to ice can cause cold injuries such as frostbite, so it is crucial to first assess the skin condition before taking any further action.

Why the other options are incorrect:

 Instruct the client regarding the need for the covering:

While educating the client is important, the priority is to assess the skin for any damage before instructing the client on the proper use of the ice pack. The skin condition should be evaluated to ensure that further injury has not occurred.

Reapply the covering after filling with fresh ice:

Reapplying the ice pack with fresh ice is not appropriate until the skin is assessed. If the skin has been damaged or frostbitten, reapplying the ice could worsen the situation. First, the skin should be inspected.

Ask the client how long the ice was applied to the skin:

While it is helpful to know how long the ice has been applied, the immediate priority is to assess the skin for any visible damage before deciding on the next steps. The duration of the ice application can be determined after ensuring the skin is intact.

Summary:

The first priority in this situation is to observe the skin for any damage or adverse effects caused by the ice pack. Once the skin condition is assessed, appropriate action, such as reapplying the ice correctly or providing further instruction to the client, can be taken.

Correct Answer: After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.

Explanation:

When a client receiving nasogastric (NG) tube feedings reports a severe coughing episode, there is a concern that the tube may have become dislodged and entered the respiratory tract. Checking the placement of the NG tube is crucial to ensure that the tube is still in the stomach and not in the lungs, as feeding into the lungs can cause aspiration pneumonia.

After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube:

This is the best action because checking the pH of the gastric aspirate is the most accurate bedside method to confirm that the tube remains in the stomach. Gastric contents usually have a pH of 1 to 5, while a pH greater than 6 suggests the tube may be in the lungs or intestines. Clearing the tube with air before aspirating ensures an accurate sample.

Why the Other Options Are Incorrect:

 Record the coughing incident. No further action is required at this time:

This is incorrect because coughing may indicate that the tube has migrated into the airway. Ignoring this sign without verifying tube placement could lead to aspiration of the feeding solution and subsequent pneumonia or respiratory distress

 Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider:

While it is essential to verify tube placement, immediately stopping the feeding without first confirming dislodgement is premature. Verifying tube location through pH testing is a faster and more appropriate initial action. The healthcare provider should be contacted only if tube displacement is confirmed.

Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling:

This method (the "whoosh" test) is no longer considered a reliable way to confirm NG tube placement because the sound can be misleading. Air can enter both the stomach and the lungs, making it difficult to distinguish correct tube placement. Evidence-based guidelines favor pH testing over auscultation.

Summary:

The best action is to verify the tube’s location by checking the pH of the aspirate after clearing the tube with air. This ensures the feeding is entering the stomach rather than the lungs. Coughing can signal tube displacement, which, if unrecognized, may lead to serious complications like aspiration pneumonia.

Correct Answer: Reassess the client's blood pressure using a larger cuff.

Explanation:

Reassess the client's blood pressure using a larger cuff:

This is the correct answer because using a cuff that is too small typically produces an artificially high blood pressure reading due to the increased pressure on the artery. Accurate measurement is critical to monitor the client’s health status and guide clinical decisions. Since the blood pressure reading obtained may be inaccurate, the most important nursing action is to verify the measurement with the correct cuff size to ensure the client's blood pressure is accurately assessed. Prompt reassessment reduces the risk of misdiagnosis and inappropriate treatment.

Why the Other Options Are Incorrect:

Tell the UAP to use a larger cuff at the next scheduled assessment:

This is incorrect because waiting until the next assessment could delay correcting an inaccurate reading, potentially leading to mismanagement of the client’s condition. The nurse must act immediately to confirm accuracy rather than waiting for the next scheduled check.

Have the unit educator review this procedure with the UAPs:

This is incorrect because while education is important for long-term improvement, the priority is to ensure immediate accuracy of the client’s blood pressure. Inaccurate readings could lead to improper intervention or missed warning signs of medical issues.

Teach the UAP the correct technique for assessing blood pressure:

This is incorrect because while education is valuable, the most urgent action is to validate the client’s blood pressure. After confirming the correct reading, the nurse can then educate the UAP to prevent future errors.

Summary:

The most important nursing action is to reassess the client's blood pressure using a larger cuff because a cuff that is too small can produce an inaccurate, falsely elevated reading. While education and future corrective actions are also necessary, immediate reassessment ensures accurate monitoring and appropriate medical management.

Correct Answer: Maintain standard precautions.

Rationale:

For an older incontinent client, the best intervention to prevent infection is to maintain standard precautions. Standard precautions, including hand hygiene, the use of gloves when handling bodily fluids, and proper cleaning techniques, are essential to reduce the risk of urinary tract infections (UTIs) and skin breakdown associated with incontinence. Older adults are more susceptible to infections due to age-related changes in immune function and skin integrity.

Why the other options are incorrect:

 Initiate contact isolation measures

Contact isolation is not necessary unless the client has an active or suspected infectious condition, such as Clostridioides difficile (C. diff) or multidrug-resistant organisms (MDROs). Implementing unnecessary isolation can cause emotional distress and is not required solely for incontinence.

Insert an indwelling urinary catheter

Inserting an indwelling urinary catheter is not recommended unless absolutely necessary due to the increased risk of catheter-associated urinary tract infections (CAUTI). Catheters should be used only when essential and removed as soon as possible to minimize infection risks.

Instruct client in the use of adult diapers

While adult diapers may manage incontinence, prolonged use without frequent changes can cause moisture buildup, leading to skin breakdown and infections like dermatitis or UTIs. Proper perineal care and frequent monitoring are more effective in preventing infection.

Summary:

The best intervention for preventing infection in an older incontinent client is to maintain standard precautions. This involves practicing strict hygiene, wearing gloves, and ensuring proper skin care. Other options, such as catheter use or unnecessary isolation, increase infection risks or are not justified without evidence of infection.

Correct Answer: Determine if pain is causing the client's tachypnea.

Explanation:

An increase in respiratory rate, known as tachypnea, after surgery can be a response to pain, anxiety, or hypoxia. In this case, it is crucial to investigate whether pain is the primary cause of the increased respiratory rate, especially in a postoperative client, as pain can lead to shallow, rapid breathing and discomfort, potentially affecting oxygenation. If pain is the cause of the tachypnea, managing the pain appropriately through medication (e.g., opioids or analgesics) can help reduce the respiratory rate and improve the client’s comfort and overall well-being. Therefore, determining if pain is the cause is the most important next step.

Why the other options are incorrect:

Encourage the client to increase ambulation in the room: While ambulation is an important part of recovery, encouraging the client to ambulate immediately after noticing tachypnea could increase discomfort and exacerbate pain or fatigue, especially if pain is contributing to the tachypnea. It is better to first address any potential causes of tachypnea, such as pain or hypoxia, before promoting physical activity.

 Offer the client a high-carbohydrate snack for energy: While nutrition is important for recovery, a high-carbohydrate snack may not directly address the cause of tachypnea. If the client is experiencing pain or hypoxia, the priority should be to manage the underlying cause of the tachypnea, not to focus on nutritional intake at this moment. A more immediate intervention is needed to stabilize the client's condition.

Force fluids to thin the client's pulmonary secretions: While hydration is essential for thinning secretions, this intervention would be more relevant if the client is having difficulty clearing secretions or has signs of respiratory infection. Tachypnea alone, without any signs of increased secretions or hypoxia, does not necessarily warrant forcing fluids. It is more important to first assess and address the possible causes of the tachypnea.

Summary:

The most appropriate intervention is to determine if pain is causing the client's tachypnea. Pain is a common cause of increased respiratory rate in postoperative clients, and addressing it through pain management will likely resolve the tachypnea and improve the client's comfort. Only after ruling out or addressing pain should other interventions be considered.

Correct Answer:  Report the results of the vital signs to the nurse.

Explanation:

When assigning tasks to unlicensed assistive personnel (UAP), it is crucial that the nurse provides clear and appropriate instructions within the UAP’s scope of practice. UAPs are trained to collect but not interpret data. The most important instruction is for the UAP to report the results of the vital signs to the nurse. This allows the nurse to evaluate the findings, interpret the significance, and determine whether further intervention is required. This is correct because it is within the UAP’s role to measure and report vital signs but not to analyze or act on abnormal findings. The nurse is responsible for assessing the client's condition, interpreting data, and initiating interventions if needed.

Why the Other Options Are Incorrect:

Remain calm with the client and record abnormal results in the chart:

This is incorrect because charting is a nursing responsibility. UAPs do not document abnormal findings in the official medical record. Furthermore, reporting abnormal results to the nurse is more urgent than simply recording them.

Notify the medication nurse immediately if the pulse or blood pressure is low:

This is incorrect because the UAP should report findings to the assigning nurse, not directly to the medication nurse. The assigning nurse is responsible for evaluating the data and deciding on further action. Additionally, the UAP is not qualified to determine what constitutes low pulse or blood pressure.

 Reassure the client that the vital signs are normal:

This is incorrect because the UAP is not qualified to interpret vital sign results or provide reassurance based on them. False reassurance could be harmful if the vital signs are abnormal and require medical attention.

Summary:

The most appropriate instruction is to report the results of the vital signs to the nurse. This ensures that the nurse—who is licensed and trained to analyze and respond to patient data—can evaluate the client’s condition accurately. Other actions exceed the UAP’s scope of practice or delay proper communication.