HESI Fundamentals Exam Test Bank

Correct Answer: A

Rationale: The correct answer is A: Hydrocolloid. Hydrocolloid dressings are recommended for stage 2 pressure injuries as they help maintain a moist wound environment, which supports the healing process. Gauze (choice B) is not ideal for stage 2 pressure injuries as it can stick to the wound bed and disrupt the healing process. Transparent film dressings (choice C) are more suitable for superficial wounds or as a secondary dressing. Alginate dressings (choice D) are typically used for wounds with heavy exudate, which is not typically seen in stage 2 pressure injuries.

Correct Answer: D

Rationale: The correct answer is D because in middle adulthood, individuals often shift their focus towards concerns related to the next generations. They reflect on their roles in guiding and supporting the younger generations. Choice A is incorrect as evaluating behavior after a social interaction is more relevant to self-awareness, which is not a specific developmental task for middle adulthood. Choice B, learning to trust others, is more commonly associated with early adulthood tasks related to forming intimate relationships. Choice C, wishing to find meaningful friendships, is more aligned with tasks associated with young adulthood and social connections.

Correct Answer: D

Rationale: The priority action for a patient with Impaired physical mobility related to pain is to assist the patient with comfort measures. By addressing pain through comfort measures, the patient will be more willing and able to move. Encouraging self-care (Choice A) may be important but addressing pain first is crucial in improving mobility. Promoting mobility (Choice B) and encouraging range of motion exercises (Choice C) are important but addressing the pain and providing comfort measures take precedence to improve the patient's physical mobility.

Correct Answer: A

Rationale: The correct answer is A: Narrowed arterial lumen. Arterial bruits are abnormal sounds caused by turbulent blood flow through narrowed or occluded arteries. This turbulent flow creates a blowing sound, which is heard as an arterial bruit. Distended jugular veins (choice B) are typically associated with venous issues, not arterial abnormalities. Impaired ventricular contraction (choice C) and asynchronous closure of the aortic and pulmonic valve (choice D) are not directly related to the audible vascular sound described in the scenario.

Correct Answer: A

Rationale: Swelling and coolness at the IV site can indicate complications such as infiltration, which can lead to tissue damage or fluid leakage into the surrounding tissues. Prompt removal of the IV catheter is essential to prevent further complications. The client reporting mild discomfort at the insertion site is common during IV therapy and does not necessarily warrant catheter removal unless there are signs of infiltration. A slower than expected infusion rate may not always necessitate IV catheter removal; the nurse should troubleshoot potential causes such as kinks in the tubing or pump malfunctions first. Just because the IV catheter is no longer needed for treatment does not automatically mean it should be removed; proper assessment and monitoring for complications are still essential.