HESI Fundamentals Quizlet

Correct Answer: B

Rationale: Positioning the client prone with a small pillow below the diaphragm helps maintain proper alignment and provides optimal pressure relief over the sacral area, reducing the risk of developing a pressure ulcer. This position redistributes pressure away from bony prominences, such as the sacrum, which is crucial in preventing ulcer formation in immobile clients.

Correct Answer: B

Rationale: Documenting the client's statement in the spiritual assessment is the best nursing action in response to his disclosure of being an agnostic. This respects the client's beliefs and preferences, ensuring that care is tailored to his individual needs. It also demonstrates a commitment to providing holistic and patient-centered care.

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.

Correct Answer: B

Rationale: In this situation, the nurse's initial action should be to reassess the client to evaluate if restraints are still required before considering reapplication. This step ensures that the restraints are only used when absolutely necessary, promoting the client's safety and autonomy. Documentation and monitoring are essential, but reassessment of the client's condition takes precedence to provide individualized care.

Correct Answer: B

Rationale: Proper handwashing technique is crucial in preventing the transmission of infections, especially in clients with burns where the risk of infection is high. It is the most effective intervention to reduce the risk of contamination and promote healing in these clients. While plasma expanders, topical antibacterial creams, and visitor restrictions are important considerations in burn care, meticulous hand hygiene takes precedence in preventing infections.