HESI Fundamentals Quizlet

Correct Answer: B

Rationale: To calculate the infusion rate, set up a ratio proportion problem: 50 ml/20 min = x ml/60 min. Cross multiply to solve: 50 60 / 20 = 150 ml/hr. Therefore, the infusion pump should be set to deliver the secondary infusion at a rate of 150 ml/hr.

Correct Answer: B

Rationale: To calculate the infusion rate, set up a ratio proportion problem: 50 ml/20 min = x ml/60 min. Cross multiply to solve: 50 60 / 20 = 150 ml/hr. Therefore, the infusion pump should be set to deliver the secondary infusion at a rate of 150 ml/hr.

Correct Answer: B

Rationale: A coagulation time of 20 minutes is prolonged, suggesting a potential bleeding disorder. Ecchymotic areas, which are areas of bruising, are common signs of abnormal bleeding. Therefore, the nurse should observe the client for ecchymotic areas to monitor for potential bleeding issues.

Correct Answer: B

Rationale: Avoiding foods high in sodium (choice B) is essential for clients with heart failure to prevent fluid retention and decrease the strain on the heart. High sodium intake can lead to fluid buildup, exacerbating heart failure symptoms. Increasing potassium intake (choice A) can be harmful in heart failure if not monitored closely. Limiting fluid intake (choice C) may be necessary in some cases, but the specific amount should be individualized based on the client's condition. Increasing vitamin K intake (choice D) is not a primary concern in heart failure management.

Correct Answer: D

Rationale: The correct answer is D. The ability to read a Snellen chart from 20 feet away indicates intact cranial nerve II (optic nerve). Hearing a whisper (A), identifying an object by touch (B), and shoulder shrugging against resistance (C) are assessments for different cranial nerves.