HESI Fundamentals Exam Test Bank

Correct Answer: A

Rationale: The correct action for the nurse to take in this situation is to complete the intermittent suction of the nasopharynx. Since the oxygen saturation remains stable at 94%, which was the initial reading, it indicates that the procedure is not causing a significant drop in oxygen levels. Stopping the suctioning or applying oxygen may not be necessary as the saturation level is within an acceptable range. Repositioning the pulse oximeter clip is unlikely to change the reading significantly. Therefore, completing the procedure maintains care consistency and effectiveness, ensuring proper airway management without unnecessary interventions. Choices B, C, and D are incorrect because repositioning the pulse oximeter clip, stopping suctioning until a higher reading is achieved, and applying oxygen are not warranted based on the stable oxygen saturation level of 94% throughout the procedure.

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. Sealing the lips around the mouthpiece is crucial for the proper use of an incentive spirometer as it helps ensure effective delivery of the inhaled medication. Choice A has been corrected to reflect the importance of sealing the lips. Choices B and C are incorrect because using the spirometer as needed throughout the day and inhaling slowly and deeply, although beneficial, do not directly address the essential technique of sealing the lips around the mouthpiece.

Correct Answer: A

Rationale: A decrease in heart rate can indicate that the fluid volume deficit is improving. In cases of fluid volume deficit, the body compensates by increasing the heart rate to maintain adequate perfusion. Therefore, a decrease in heart rate after fluid resuscitation suggests that the body's perfusion status is improving. Choices B, C, and D are incorrect because fluid volume deficit typically causes tachycardia, not a decrease in heart rate, and would not result in a decrease in blood pressure or an increase in respiratory rate as primary signs of improvement.

Correct Answer: A

Rationale: Using an open posture is crucial when demonstrating empathy to a client. This body language conveys openness, understanding, and a willingness to listen, creating a safe space for the client to express themselves. Establishing and maintaining eye contact is also important as it fosters a sense of connection and validation for the client. Writing down what the client says is essential for accurate documentation and memory but does not directly contribute to demonstrating empathic presence. Nodding in agreement with the client throughout the conversation may show attentiveness, but it does not necessarily reflect empathy or active listening as it could be misinterpreted as simply agreeing with what is being said.