Fundamentals HESI

Correct Answer: B

Rationale: Using pillows to keep the client's extremities in a functional position is crucial in preventing joint contractures. This intervention helps maintain proper alignment of the joints and reduces the risk of contractures by preventing prolonged positioning that can lead to muscle shortening. Encouraging the client to perform active range-of-motion exercises (Choice A) is beneficial for maintaining mobility but may not be the most important intervention to prevent joint contractures. Placing the client in a prone position for 30 minutes each day (Choice C) can be helpful for preventing pressure ulcers but is not directly related to preventing joint contractures. Performing passive range-of-motion exercises on the affected side (Choice D) can aid in maintaining joint flexibility but may not be as crucial as using pillows to prevent joint contractures.

Correct Answer: A

Rationale: Placing the client in Trendelenburg's position is the appropriate action when providing chest physiotherapy for a client with left lower lobe atelectasis. This position helps mobilize secretions from the lower lobes of the lungs, aiding in their clearance. Trendelenburg's position promotes drainage from the affected area. Positioning the client in an upright sitting position (Choice B) would not facilitate the drainage of secretions from the affected lobe. Administering bronchodilators after the procedure (Choice C) is not directly related to chest physiotherapy and the treatment of atelectasis. Performing chest percussion and vibration while the client is lying flat (Choice D) may not effectively target the lower lobes where the atelectasis is located.

Correct Answer: A

Rationale: When a client has fluid overload, the nurse's first action should be to evaluate electrolytes. Electrolyte levels can be significantly affected by fluid imbalances, and assessing them will guide the nurse in determining the appropriate interventions. Restricting fluid intake (choice B) may be necessary but is not the initial priority. Administering diuretics (choice C) should be based on the electrolyte evaluation and overall assessment. Monitoring vital signs (choice D) is essential but does not provide direct information on the client's electrolyte status, which is crucial in managing fluid overload.

Correct Answer: A

Rationale: The correct answer is A: Spinach. Spinach is high in oxalate, a compound that can contribute to the formation of calcium oxalate kidney stones. Therefore, advising the client to avoid spinach is crucial in reducing the risk of stone recurrence. Bananas (choice B) are not high in oxalate and do not directly contribute to the formation of calcium oxalate stones, so they do not need to be avoided. Similarly, choices C and D, chicken, and rice, are not typically associated with high oxalate content, making them safe choices and do not need to be avoided specifically to prevent calcium oxalate kidney stones.

Correct Answer: B

Rationale: Choice B is the correct answer because the Braden Scale measures six elements: Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction, and Shear. The other choices are incorrect because: Choice A states that the client's age is not a factor in the measurement, which is accurate as age is not included in the Braden Scale. Choice C incorrectly states that a lower score indicates a higher risk of pressure ulcers, which is the opposite of how the Braden Scale works. Choice D inaccurately describes the scoring range of each element on the Braden Scale, which is not from 1 to 4 points but rather from 1 to 3.