Question

The nurse is planning to provide mouth care for an unconscious client. Which statement is accurate in regard to implementing mouth care for this client?

Answer 1

Correct Answers:

Positioning the unconscious client with the head turned to the side is the key to providing safety during mouth care.

Rationale :

🟦 Turning the head to the side prevents aspiration of secretions during mouth care.

🟦 Unconscious clients lack a gag reflex, making airway protection essential.

🟦 Side positioning allows saliva and fluids to drain safely from the mouth.

🟦 This is the safest strategy to prevent aspiration pneumonia.

🟦 Proper positioning maintains airway patency throughout the procedure.

Unconscious clients need less frequent care

🟦 They need more frequent care due to lack of swallowing.

🟦 Increased oral dryness raises infection and breakdown risk.

Glycerin swabs are best

🟦 Glycerin causes drying and mucosal irritation.

🟦 Not recommended for routine oral care.

Brushing should be avoided

🟦 Brushing improves oral hygiene and prevents infection.

🟦 Safe with proper suctioning and positioning.

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Answer 2

Correct Answers:

Retake vital signs
Assess the client

Rationale :

🟨 Confirms whether the abnormal BP is accurate or an error.

🟨 Ensures no equipment malfunction or improper cuff placement.

🟨 Vital signs must be validated before action is taken.

Assess the client

🟨 Assessment determines whether symptoms such as headache, confusion, or chest pain are present.

🟨 Clinical assessment guides urgency and next steps in management.

🟨 Objective findings are essential before interventions or notifying providers.

Implement seizure precautions

🟨 Elevated BP alone does not indicate seizure risk.

🟨 No neurologic symptoms reported.

Lower the head of the bed

🟨 Contraindicated because lowering HOB can increase BP.

🟨 Not appropriate without assessment.

Encourage fluid intake

🟨 Fluids increase blood volume, worsening BP.

🟨 Unsafe for hypertensive readings.

Call rapid response

🟨 RRT is for life-threatening deterioration.

🟨 Assessment must happen first.

Administer ACE inhibitor

🟨 Not safe before confirming BP and ruling out causes like pain or anxiety.

🟨 Must ensure correct dosing and provider direction.

Teach relaxation techniques

🟨 Not appropriate before assessing and validating vital signs.

🟨 Delays needed evaluation.

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Answer 3

Correct Answers:

Open the sterile field facing the body.
Leave the sterile field to gather additional supplies.

Rationale :

🟪Open sterile field facing the body Opening toward the body increases risk of contaminating the field.

🟪 Clothing or arms may touch the sterile surface.

🟪 Must always open away from oneself.

🟪 Leaving the sterile field Once left unattended, sterility cannot be guaranteed.

🟪 Air contamination or accidental contact may occur.

🟪 Sterile fields require constant monitoring.

Set up prior to use

🟪Setting up just before use maintains sterility.

🟪This is the recommended practice.

Inspect for punctures

🟪 This ensures items are sterile before opening.

🟪 Does not compromise sterility.

Using sterile gloves

🟪 Sterile gloves are required when handling the sterile field.

🟪 This maintains sterility.

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Answer 4

Correct Answers:

Call the HCP to return and provide additional explanation.

Rationale :

🟧 Only the HCP performing the procedure may explain risks, benefits, and technique.

🟧 Hesitation signals a lack of understanding, requiring provider clarification.

🟧 Nurses witness consent, not provide detailed procedural explanation.

🟧 Accurate information supports true informed consent.

🟧 Calling the HCP prevents misinformation and protects patient autonomy.

Nurse explaining procedure

🟧 Nurses cannot explain procedural details or answer medical questions.

🟧 Doing so violates informed consent rules.

Next of kin providing consent

🟧 Next of kin cannot consent when the patient is competent.

🟧 This violates patient autonomy.

Postpone the procedure

🟧 Nurse cannot delay procedures without HCP involvement.

🟧 Must refer back to the provider first.

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Answer 5

Correct Answers:

Ask the client for a description of the exercise schedule that is being followed.

Rationale :

🟦 High-intensity exercise performed too close to bedtime can increase sympathetic stimulation, causing insomnia, so assessing timing is essential.

🟦 A detailed exercise schedule helps the nurse identify factors such as late-night workouts, duration, or overstimulation.

🟦 Assessment is the first step of the nursing process, ensuring safe and individualized recommendations.

🟦 Understanding frequency and timing allows the nurse to determine whether exercise-induced cortisol or adrenaline spikes are contributing to sleep difficulty.

🟦 Thorough assessment prevents unsafe or incorrect advice and supports a targeted intervention plan.

Determine weight lost

🟦 Weight loss does not directly explain sleep disturbance.

🟦 Does not address the root cause related to exercise timing.

Encourage exercise every day

🟦 Daily high-intensity workouts can worsen sleep problems and cause overtraining.

🟦 Recommending without assessment risks harm.

Lifestyle changes take weeks

🟦 Minimizing symptoms without assessment delays identification of modifiable causes.

🟦 Does not address the client’s immediate sleep disturbance.

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Answer 6

Correct Answers:

0.8

Rationale :

🎀Ordered dose = 8,200 units

🎀Supply on vial = 10,000 units per 1 mL

Formula:

🎀Volume to give (mL) = Ordered dose (units) ÷ Concentration (units/mL)

Substitute:

🎀Volume (mL) = 8200 ÷ 10000

🎀Volume (mL) = 0.82 mL

🎀Round to the nearest tenth:

0.82 mL → 0.8 mL

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Answer 7

Correct Answers:

Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client.

Rationale :

🟨 Droplet precautions require a standard surgical mask, not a particulate/N95 mask.

🟨 Influenza spreads through large respiratory droplets, which are blocked by surgical masks.

🟨 Care tasks such as bathing can be safely done with droplet PPE: mask, gloves, gown.

🟨 N95 masks are used for airborne diseases, not droplet illnesses.

🟨 Ensuring correct PPE prevents inappropriate assignment changes and maintains safe staffing.

Determine which staff have fitted particulate masks

🟨 Unnecessary because N95 masks are not required for droplet precautions.

🟨 This wastes time and delays patient care.

Wear surgical mask briefly, then obtain N95

🟨 Implies an N95 is needed, which is incorrect for influenza.

🟨 Adding unnecessary steps increases workplace confusion.

Send UAP to be fitted for N95 immediately

🟨 This is only required for airborne diseases like TB, not droplet ones.

🟨 Delays patient care and misuses resources.

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Answer 8

Correct Answers:

The healthcare provider must project that the client has 6 months or less to live.
A client must be willing to accept palliative care, not curative care.

Rationale :

🟪 HCP must project 6 months or less This is a CMS/Medicare requirement for hospice enrollment.

🟪 Prognosis must be documented by the healthcare provider.

🟪 Ensures hospice care is appropriate for end-of-life needs.

🟪palliative, not curative care Hospice requires the client to shift from curative treatment to comfort-focused care.

🟪 Aligns treatment goals with quality of life, not disease reversal.

🟪 This requirement ensures client understanding of hospice philosophy.

Hospice is covered under Medicare Part B

🟪 Hospice is actually covered under Medicare Part A, not Part B.

🟪 Incorrect benefit category.

All medications except pain treatment stopped

🟪 Hospice continues meds for comfort, not only pain.

🟪 Many symptom-relief medications remain active.

All family must agree

🟪 Only the client decides. Family agreement is not required.

🟪 Consent cannot depend on family opinion.

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Answer 9

Correct Answers:

Position the client supine for a few minutes.

Rationale :

🟫 Orthostatic BP requires an initial baseline measurement after resting supine.

🟫 Rest allows blood volume to redistribute and creates a stable hemodynamic reference.

🟫 Without supine baseline, orthostatic comparisons (sitting/standing) are invalid.

🟫 Ensuring rest prevents inaccurate readings caused by recent movement or exertion.

🟫 This is consistent with evidence-based guidelines for diagnosing orthostatic hypotension.

Record pulse first

🟫 Pulse is recorded during assessment, but not the first priority.

🟫 Must obtain baseline BP before any comparison.

Assist the client to stand

🟫 Standing comes later, after baseline supine and seated readings.

🟫 Standing first risks sudden syncope.

Apply cuff securely

🟫 Necessary but not the essential first step.

🟫 The client must rest supine before cuff application matters.

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Answer 10

Correct Answers:

While washing, keep hands and forearms lower than the elbows.
Rub hands together to create lather for at least 15 seconds.
Dry hands starting at the fingertips and work upward towards the elbows.

Rationale :

🟦 Keeping hands lower promotes drainage of water and microbes away from clean areas.

🟦 This position prevents contaminated water from flowing toward the arms.

🟦 Gravity helps reduce cross-contamination risk.

🟦 This technique aligns with standard infection-control guidelines.

🟦 Maintaining downward flow ensures the cleanest area remains closest to the elbows.

🟦Rub hands for at least 15 seconds Rubbing for ≥15 seconds effectively removes transient microorganisms.

🟦 Creates enough friction to lift oil, dirt, and pathogens from skin surfaces.

🟦 Evidence-based guidelines recommend 15–20 seconds for proper microbial removal.

🟦 Longer friction improves cleansing of nailbeds, knuckles, and wrists.

🟦 This timing is the minimum required for proper hand hygiene.

🟦Dry from fingertips toward elbows Drying from cleanest (fingertips) toward elbows prevents recontamination.

🟦 Ensures that water, which carries microbes, flows away from hands.

🟦 Drying direction matches the principle of moving from clean to less clean.

🟦 Proper drying prevents microbial growth on moist skin.

🟦 Correct drying technique is essential for maintaining aseptic practice.

Dry from elbows downward

🟦 This moves moisture and microbes toward the hands, causing contamination.

🟦 Violates the clean-to-dirty drying principle.

Keep hands/forearms upward with bent elbows

🟦 This position allows contaminated water to run toward the arms.

🟦 Increases infection risk by reversing gravity flow.

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HESI BSN 225-RN Fundamentals Fall-2025

No.

1 :
The nurse is planning to provide mouth care for an unconscious client. Which statement is accurate in regard to implementing mouth care for this client?

2 :
The client is a 48-year-old male in the hospital for cellulitis to the left leg.

Answer Options

3 :
When preparing a sterile field, which action(s) by the nurse would compromise the sterility? Select all that apply.

5 :
A client tells the nurse about doing a high intensity workout program to help with losing weight but now describes having difficulty getting to sleep at night. Which action should the nurse implement?

7 :
The nurse has assigned an unlicensed assistive personnel (UAP) to assist bathing a client who has influenza and is on droplet precautions. The UAP requests a change in assignment, informing that she has not yet been fitted for a particulate mask. Which action should the nurse take?

8 :
A family member of a frail older adult asks the nurse about eligibility requirements for hospice care. Which information should the nurse provide? Select all that apply.

9 :
When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?

10 :
Which step(s) indicate that the nurse is following recommended procedure for handwashing? Select all that apply.

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HESI BSN 225-RN Fundamentals Fall-2025

No.

1 : The nurse is planning to provide mouth care for an unconscious client. Which statement is accurate in regard to implementing mouth care for this client?

2 : The client is a 48-year-old male in the hospital for cellulitis to the left leg.

Answer Options

3 : When preparing a sterile field, which action(s) by the nurse would compromise the sterility? Select all that apply.

5 : A client tells the nurse about doing a high intensity workout program to help with losing weight but now describes having difficulty getting to sleep at night. Which action should the nurse implement?

7 : The nurse has assigned an unlicensed assistive personnel (UAP) to assist bathing a client who has influenza and is on droplet precautions. The UAP requests a change in assignment, informing that she has not yet been fitted for a particulate mask. Which action should the nurse take?

8 : A family member of a frail older adult asks the nurse about eligibility requirements for hospice care. Which information should the nurse provide? Select all that apply.

9 : When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?

10 : Which step(s) indicate that the nurse is following recommended procedure for handwashing? Select all that apply.

1 :
The nurse is planning to provide mouth care for an unconscious client. Which statement is accurate in regard to implementing mouth care for this client?

2 :
The client is a 48-year-old male in the hospital for cellulitis to the left leg.

3 :
When preparing a sterile field, which action(s) by the nurse would compromise the sterility? Select all that apply.

5 :
A client tells the nurse about doing a high intensity workout program to help with losing weight but now describes having difficulty getting to sleep at night. Which action should the nurse implement?

7 :
The nurse has assigned an unlicensed assistive personnel (UAP) to assist bathing a client who has influenza and is on droplet precautions. The UAP requests a change in assignment, informing that she has not yet been fitted for a particulate mask. Which action should the nurse take?

8 :
A family member of a frail older adult asks the nurse about eligibility requirements for hospice care. Which information should the nurse provide? Select all that apply.

9 :
When performing blood pressure measurements to assess for orthostatic hypotension, which action should the nurse implement first?

10 :
Which step(s) indicate that the nurse is following recommended procedure for handwashing? Select all that apply.