HESI Fundamentals Exam

Correct Answer: A

Rationale: Choice A is correct because performing ankle and knee exercises every hour helps prevent contractures and other adverse effects of immobility. Contractures are a common complication of immobility, and range of motion (ROM) exercises can help maintain joint flexibility and prevent contractures. This statement indicates an understanding of the teaching provided by the healthcare provider. Choices B, C, and D are incorrect. Holding the breath when rising from a sitting position can increase the risk of orthostatic hypotension, not reduce adverse effects of immobility. Removing antiembolic stockings while in bed can compromise their effectiveness in preventing deep vein thrombosis (DVT), which is not a measure to reduce immobility-related complications. Having a partner help change positions every 4 hours may not be frequent enough to prevent immobility-related complications effectively; changing positions more frequently is usually recommended to prevent issues like pressure ulcers and muscle stiffness.

Correct Answer: A

Rationale: The correct answer is option A: Inability of the toddler to cry or speak. In cases of choking, the inability to cry or speak indicates a severe airway obstruction where the Heimlich maneuver is necessary to clear the obstruction and establish a patent airway. Option B, coughing forcefully, represents a partial obstruction where the child can still move air, making the Heimlich maneuver not immediately necessary. Option C, gagging but able to breathe, suggests a partial obstruction where air is moving, and the child can still breathe, not requiring immediate intervention like the Heimlich maneuver. Option D, wheezing during respiration, is more indicative of a lower airway issue such as asthma rather than an upper airway obstruction that necessitates the Heimlich maneuver.

Correct Answer: C

Rationale: The correct answer is C: Respiratory distress. In Guillain-Barre syndrome, respiratory distress is the most concerning finding as it can indicate progression to respiratory failure, which is a life-threatening complication. Loss of reflexes in the legs and muscle weakness in the arms are common manifestations of the condition but may not be as immediately life-threatening as respiratory distress. Decreased peripheral sensation is also a common symptom but is not as critical as respiratory distress in terms of immediate patient safety and management.

Correct Answer: A

Rationale: The correct action the nurse should take first is to auscultate bowel sounds. This step is crucial to assess bowel activity before proceeding with palpation or administering medications. Assessing bowel sounds can provide valuable information about bowel motility and potential obstructions. Administering an antiemetic or offering pain medication may be necessary but should come after assessing bowel sounds to ensure appropriate treatment. Palpating the abdomen should be avoided initially to prevent potential discomfort or complications, especially if there is suspected abdominal pathology.

Correct Answer: B

Rationale: In a mass casualty scenario, the triage nurse would prioritize the toddler with severe deep abrasions covering over 98% of the body for treatment last. This child is categorized as 'expectant' due to the extensive injuries, which are unlikely to be survivable even with immediate treatment. The other choices describe injuries that are serious but have a higher likelihood of survival with appropriate and timely intervention. The infant with an intermittent bulging anterior fontanel may have increased intracranial pressure requiring urgent evaluation, the preschooler with leg fractures can be stabilized and treated effectively, and the school-age child with singed hair likely has superficial burns which can be managed promptly.