HESI Fundamentals 2023 Quizlet

Correct Answer: D

Rationale: The statement 'When I place the baby in a supine position, that's how I find the baby' supports the presence of atonic cerebral palsy. In this type of cerebral palsy, the child may have poor muscle tone, making it difficult for them to roll from a back-lying position. This inability to roll indicates a lack of muscle tone, which is a characteristic feature of atonic cerebral palsy. Choices A, B, and C do not directly relate to the muscle tone issues typical of atonic cerebral palsy. Choice A focuses on a lack of grasp response, which may suggest motor issues but not specifically atonic cerebral palsy. Choice B refers to visual tracking, and choice C is about the startle reflex, neither of which are defining characteristics of atonic cerebral palsy.

Correct Answer: D

Rationale: The correct answer is to have the client use a trapeze bar when changing positions. This action helps in repositioning without causing friction or shearing, which can lead to skin breakdown. Placing the client in high-Fowler's position (Choice A) may not directly prevent skin breakdown related to limited mobility. Increasing carbohydrate intake (Choice B) is not relevant to preventing skin breakdown. Massaging reddened areas with lotion (Choice C) can potentially cause more harm by increasing friction and damaging the skin further, rather than preventing breakdown.

Correct Answer: A

Rationale: The correct action for the nurse to take when a client has a prescription for a 24-hour urine collection is to discard the first voiding. This initial voiding is typically not collected to allow for the accurate start of the 24-hour collection period. All subsequent urine voided within the specified time frame is then collected. Including the last voiding in the collection is important to ensure that the full 24-hour period is covered. It is essential to keep the urine cool by storing it in a single container on ice to prevent degradation of components. Instructing the client to stop midstream and finish urinating into the specimen container is not required for a 24-hour urine collection and is an unnecessary step.

Correct Answer: D

Rationale: When caring for clients with Clostridium difficile infection, it is important to prevent the transmission of spores. Having family members wear a gown and gloves when visiting helps reduce the spread of the infection. Choices A, B, and C are incorrect because assigning the client to a room with a negative air-flow system, using alcohol-based hand sanitizer, and cleaning surfaces with a phenol solution are not specific measures targeted at preventing the transmission of Clostridium difficile spores.

Correct Answer: A

Rationale: Correct! When a client is taking furosemide (Lasix), monitoring potassium levels is crucial due to the potential for hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss through increased urine output. Low potassium levels can predispose the client to cardiac dysrhythmias. Sodium, calcium, and magnesium levels are not typically affected by furosemide to the same extent as potassium, making them less critical to monitor in this scenario.