HESI Practice Test for Fundamentals

Correct Answer: C

Rationale: The rationale behind checking for impaired skin integrity in an immobile patient is that pressure reduces circulation to the affected tissue. Prolonged pressure on specific body parts can lead to reduced blood flow to those areas, causing tissue damage and potentially leading to pressure ulcers. Choices A, B, and D are incorrect because inadequate blood flow causing decreased tissue ischemia, limited caloric intake leading to thicker skin, and decreased verbalization of skin care needs are not directly related to the rationale for checking for impaired skin integrity in immobile patients.

Correct Answer: D

Rationale: The correct answer is D. Turning a patient's head with a neck injury to the side when giving oral care can lead to harm or further injury. The neck should be kept in a neutral position to prevent exacerbation of the injury. Choices A, B, and C are not actions that require immediate nurse intervention. Not offering a backrub, not washing a patient's hair, or turning off the television are not critical issues that pose harm to the patient's well-being or safety.

Correct Answer: A

Rationale: Administering pain medication before the dressing change is the priority action to help manage the client's pain effectively. This intervention ensures that the client is comfortable during the procedure. Changing the dressing quickly may cause more discomfort to the client. Providing reassurance is important but does not address the immediate pain concern. Using a less painful dressing technique may be helpful, but administering pain medication first is the priority to address the client's pain promptly.

Correct Answer: C

Rationale: The correct answer is C. Checking the blood pressure of a 2-hour postoperative client is a task that can be safely delegated to an unlicensed assistive personnel (UAP) as it falls within their scope of practice. This task is routine and does not require specialized nursing knowledge or critical decision-making. Options A, B, and D involve tasks that require a higher level of training and critical thinking beyond the scope of a UAP. Taking a history, adjusting tube feeding rates, and monitoring a client receiving chemotherapy are responsibilities that should be performed by licensed healthcare providers who have the necessary skills and training.

Correct Answer: D

Rationale: When using wrist restraints, it is important to allow room for two fingers to fit between the client's skin and the restraints. This practice ensures proper circulation and comfort for the client while still providing the necessary level of security. Choice A is incorrect because removing restraints every 4 hours may compromise the effectiveness of restraint use. Choice B is incorrect as restraints should not be attached to the side of the bed where they could cause harm or be tampered with by the client. Choice C is incorrect because allowing minimal movement may lead to discomfort and compromise proper circulation.