Question

The nurse determines that a client's oxygen flow meter is set at 1.5 L/minute, the nasal cannula is in place in the client's nares, and the oxygen tubing is disconnected from the flow meter. Which action would the nurse implement?

Answer 1

Correct Answers:

Connect the tubing to the flow meter.

Rationale :

🍊 The oxygen tubing is disconnected from the flow meter, meaning the client is currently not receiving the prescribed supplemental oxygen despite the nasal cannula being positioned correctly.

🍊 The nurse should immediately connect the oxygen tubing to the flow meter to restore the prescribed oxygen delivery.

🍊 Oxygen cannot travel from the flow meter through the nasal cannula when there is a break in the oxygen-delivery system.

🍊 The flow meter is already set at 1.5 L/min, so the nurse should maintain the prescribed flow rate rather than changing it without an indication or prescription.

🍊 Correcting an obvious equipment problem takes priority because it directly restores the client's prescribed oxygen therapy.

🍊 After reconnecting the tubing, the nurse should verify that oxygen is flowing through the cannula and reassess the client's respiratory status.

🍊 The nurse should also monitor oxygen saturation, respiratory rate, work of breathing, and overall clinical response to oxygen therapy.

🍊 Therefore, the immediate nursing action is to connect the tubing to the flow meter.

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Answer 2

Correct Answers:

Time the bottle was opened.
Date opened.
Nurse's initials.

Rationale :

✅ Time the bottle was opened

🌸 The nurse should label the opened sterile saline bottle with the time it was opened.

🌸 Recording the opening time allows staff to determine how long the solution has been open and potentially exposed to contamination.

🌸 Sterile solutions must be handled according to facility policies regarding their usable period after opening.

🌸 Accurate timing helps prevent use of a solution beyond the period during which its sterility can be assured.

🌸 This is particularly important in the perioperative environment, where maintaining strict aseptic technique reduces surgical-site infection risk.

🌸 Labeling also allows another healthcare professional to immediately determine when the container was first opened.

🌸 The information promotes safe handling, accountability, and infection prevention.

🌸 Therefore, the time the bottle was opened should be included on the label.

✅ Date opened

🌸 The date opened should be documented on the bottle when the sterile irrigation solution is opened.

🌸 The date works together with the opening time to identify exactly when the container's sterile seal was broken.

🌸 This allows staff to determine whether the solution remains acceptable for use according to facility policy.

🌸 Clearly dating opened containers decreases the possibility of accidentally using an outdated or potentially contaminated solution.

🌸 Accurate labeling is an important component of infection-control practices in perioperative care.

🌸 The date also provides clear information when multiple staff members might handle the solution during the course of care.

🌸 Proper documentation supports traceability and accountability for opened sterile supplies.

🌸 Therefore, the nurse should include the date opened on the saline bottle.

✅ Nurse’s initials

🌸 The nurse should place their initials on the opened bottle to identify the person who opened and labeled the solution.

🌸 Initialing the container establishes accountability for appropriate handling and labeling.

🌸 Other members of the perioperative team can determine who prepared the solution if clarification becomes necessary.

🌸 This supports appropriate communication among healthcare professionals working within the sterile environment.

🌸 Initials accompany the date and time opened to create a complete identification of when and by whom the container was opened.

🌸 Proper labeling reduces uncertainty about the solution's handling and helps maintain patient safety.

🌸 The practice also supports compliance with institutional policies for handling opened sterile solutions.

🌸 Therefore, the nurse's initials should be included on the bottle.

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Answer 3

Correct Answers:

Involve and educate clients in medication administration
Question unusually large or small doses
Use at least 2 client identifiers before administering a dose
Do not allow other activity to interrupt medication administration

Rationale :

✅ Involve and educate clients in medication administration

🌻 Involving clients in medication administration provides an additional safety check before a medication is given.

🌻 The nurse should explain the medication name, purpose, and expected dose whenever appropriate.

🌻 An informed client might recognize that the medication or dose being offered differs from their usual medication regimen.

🌻 This client was prescribed clindamycin 300 mg IVPB every 6 hr, making familiarity with the prescribed therapy potentially helpful.

🌻 Encouraging clients to ask questions about unfamiliar medications promotes active participation in medication safety.

🌻 Client education does not replace the nurse's responsibility to perform the rights of medication administration, but it adds another safeguard.

🌻 Effective communication between the nurse and client can help identify discrepancies before medication administration.

🌻 Therefore, involving and educating the client could have helped prevent this wrong-client/wrong-dose medication error.

✅ Question unusually large or small doses

🌻 The prescribed clindamycin dose was 300 mg, but the nurse administered 800 mg, which represents a substantial difference.

🌻 Nurses should compare the prepared medication with the medication administration record and current prescription before administration.

🌻 A dose that appears significantly different from the expected dose should cause the nurse to stop and verify the medication.

🌻 Questioning an unexpected dose can identify a medication intended for another client or an incorrect preparation.

🌻 The nurse should never administer a medication simply because it was already prepared or available.

🌻 The medication label, prescription, dose, route, and client should be verified as part of the medication rights.

🌻 Recognizing that 800 mg did not match the prescribed 300 mg could have prevented administration of the incorrect dose.

🌻 Therefore, questioning an unusually large dose is an important medication-error prevention strategy.

✅ Use at least 2 client identifiers before administering a dose

🌻 The nurse returned from the emergency and entered the wrong client's room, creating a wrong-client medication error.

🌻 At least two approved client identifiers should be verified immediately before administering medications.

🌻 Appropriate identifiers commonly include the client's name and date of birth and comparison with the identification band and MAR.

🌻 The client's room number should never be used as a client identifier because clients can be transferred or the nurse can enter the wrong room.

🌻 Correct identification would have revealed that the clindamycin being carried was not intended for the client receiving it.

🌻 Identification should occur even when the nurse believes they recognize or know the client.

🌻 Consistently performing this safety check helps prevent wrong-client medication administration.

🌻 Therefore, using at least two client identifiers could have directly prevented this error.

✅ Do not allow other activity to interrupt medication administration

🌻 The medication-administration process was interrupted when the nurse was paged for a rapid response.

🌻 Interruptions increase the risk of losing track of the medication, dose, client, and stage of preparation.

🌻 After responding to an unavoidable emergency, the nurse should restart the appropriate medication-safety checks before administering any medication.

🌻 Carrying the medication in a pocket contributed to loss of control over the medication-administration process.

🌻 The nurse subsequently returned to the wrong room, demonstrating how interruption can contribute to medication errors.

🌻 Medications should remain properly secured and associated with the correct client throughout preparation and administration.

🌻 Minimizing interruptions during medication preparation and administration reduces preventable wrong-dose and wrong-client errors.

🌻 Therefore, preventing or appropriately managing interruptions could have helped avoid this medication error.

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Answer 4

Correct Answers:

Release the air and reinflate the cuff to 30 mm Hg above the client's previous systolic reading.

Rationale :

🌼 Hearing loud Korotkoff sounds immediately when the cuff begins to deflate indicates that the cuff was not inflated high enough to occlude the brachial artery completely.

🌼 The client's actual systolic blood pressure is likely higher than 160 mm Hg, so the true first Korotkoff sound could have been missed.

🌼 The nurse should stop the current measurement and completely deflate the cuff before attempting another measurement.

🌼 The cuff should then be reinflated to approximately 30 mm Hg above the client's previously identified systolic pressure to ensure complete arterial occlusion.

🌼 Proper cuff inflation allows the nurse to accurately identify the first Korotkoff sound, which represents systolic blood pressure.

🌼 Continuing from an insufficient inflation pressure could result in a falsely low systolic blood pressure reading.

🌼 Accurate measurement is especially important when the client's systolic pressure might be higher than anticipated.

🌼 Therefore, the nurse should release the air and repeat the measurement after inflating the cuff sufficiently above the client's systolic pressure.

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Answer 5

Correct Answers:

0.5

Rationale :

Formula:

Tablets to administer = Dose prescribed ÷ Dose available

➤ Dose prescribed = 8 mg

➤ Dose available = 16 mg/tablet

8 mg ÷ 16 mg = 0.5 tablet

∴ 0.5 tablet

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Answer 6

Correct Answers:

Starts at wound site and moves outward using circular motions.

Rationale :

💎 Effective wound cleansing follows the principle of cleaning from the least contaminated area toward the more contaminated area.

💎 For a typical wound, the nurse begins at the center or wound site and cleans outward toward the surrounding skin.

💎 Using an outward circular motion prevents microorganisms from the surrounding skin from being carried back into the cleaner wound area.

💎 Each cleansing stroke should progress away from the wound rather than returning toward the center.

💎 The nurse should use a new sterile gauze or swab for subsequent cleansing strokes to prevent reintroducing microorganisms.

💎 Cleansing should be performed gently because excessive mechanical force can damage new granulation tissue and delay healing.

💎 Appropriate wound-cleansing technique helps reduce microbial contamination while protecting healthy tissue.

💎 Therefore, beginning at the wound and moving outward using circular motions demonstrates effective wound cleansing technique.

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Answer 7

Correct Answers:

A private room with both contact and airborne precautions.

Rationale :

⚽ Varicella-zoster virus (VZV), which causes chickenpox, requires both airborne and contact precautions in addition to standard precautions.

⚽ Airborne precautions are necessary because VZV can spread through small infectious particles that remain suspended in the air.

⚽ Contact precautions are required because transmission can also occur through direct contact with fluid from the client's vesicular skin lesions.

⚽ The client should preferably be placed in a private airborne infection isolation room (AIIR) with negative-pressure ventilation.

⚽ Healthcare personnel should follow appropriate respiratory protection requirements when entering the room and use gowns and gloves according to contact-precaution procedures.

⚽ Susceptible healthcare workers and visitors without evidence of varicella immunity should avoid exposure whenever possible.

⚽ Precautions are generally maintained until the client's vesicular lesions have dried and crusted, eliminating the major source of infectious virus.

⚽ Therefore, a private room with contact and airborne precautions provides the appropriate infection-control environment.

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Answer 8

Correct Answers:

Offer mouth care before and after every meal.

Rationale :

🎯 Painful mouth sores during chemotherapy are commonly caused by oral mucositis, which results from damage to rapidly dividing cells of the oral mucosa.

🎯 Providing frequent oral care helps keep the mouth clean, moist, and free of food particles that can further irritate ulcerated tissues.

🎯 Offering mouth care before meals can decrease oral discomfort and make eating and drinking easier for the client.

🎯 Providing mouth care after meals removes food debris that could irritate lesions or promote bacterial growth.

🎯 Chemotherapy can also cause immunosuppression, making meticulous oral hygiene important for reducing the risk of secondary oral infections.

🎯 Oral care should be performed gently using a soft-bristled toothbrush and nonirritating rinses as appropriate.

🎯 The nurse should also assess the mouth regularly for ulceration, bleeding, infection, dryness, and worsening mucosal damage.

🎯 Therefore, providing mouth care before and after every meal is an appropriate intervention for reducing discomfort associated with chemotherapy-induced mucositis.

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Answer 9

Correct Answers:

Using the syringe to remove the specimen from the catheter.

Rationale :

🧿 The nurse should wear gloves when using the syringe to obtain urine from the indwelling urinary catheter because there is potential contact with urine and contaminated equipment.

🧿 Standard precautions require gloves whenever contact with blood, body fluids, secretions, excretions, mucous membranes, or nonintact skin is anticipated.

🧿 Urine is considered a body fluid, making gloves appropriate during direct specimen collection.

🧿 Gloves protect the nurse's hands from accidental exposure while manipulating the catheter specimen port and syringe.

🧿 The specimen port should be disinfected appropriately before accessing it to reduce the risk of introducing microorganisms into the urinary system.

🧿 After obtaining the specimen, the nurse should remove the gloves and perform appropriate hand hygiene.

🧿 The specimen should then be placed in a properly labeled, leak-resistant container and secured in a biohazard transport bag.

🧿 Therefore, gloves are specifically required while using the syringe to remove urine from the catheter.

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Answer 10

Correct Answers:

Fits the crutch 2 finger widths from axilla.

Rationale :

🍊 Properly fitted crutches should have approximately 2 to 3 finger widths of space between the top of the crutch and the client's axilla.

🍊 This spacing prevents the client's body weight from being supported directly through the axillary area.

🍊 Pressure from the crutch pad against the axilla can compress the brachial plexus and blood vessels, potentially causing nerve or circulatory injury.

🍊 The client should support body weight primarily through the hands and handgrips, rather than resting on the axillary pads.

🍊 Correct crutch height also promotes proper posture, balance, and mobility during ambulation.

🍊 The elbows should remain slightly flexed, approximately 20° to 30°, when the client holds the handgrips.

🍊 Proper crutch fitting reduces the risk for falls, nerve damage, discomfort, and ineffective gait mechanics.

🍊 Therefore, positioning the crutch approximately 2 finger widths below the axilla demonstrates correct understanding of crutch use.

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RN HESI Fundamentals Exam 3

No.

1 :
The nurse determines that a client's oxygen flow meter is set at 1.5 L/minute, the nasal cannula is in place in the client's nares, and the oxygen tubing is disconnected from the flow meter. Which action would the nurse implement?

2 :
The perioperative nurse is preparing the supplies for a surgery. After opening a sterile bottle of saline for irrigation, how should the nurse label the opened bottle? Select all that apply.

3 :
The client is a 59-year-old female with cellulitis following a surgical procedure to repair a fracture 2 weeks ago. She has a history of seasonal allergies and

Answer Options

4 :
While assessing a client's blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm Hg. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. Which action should the nurse implement next?

5 :
A client with hypertension has a prescription for 8 mg of candesartan cilexetil PO daily. The medication is available in a 16 mg tablet. How many tablets should the nurse administer? (Enter numeric value only, rounded to the tenth.)

6 :
The charge nurse is observing a new graduate's performance of wound care. Which technique indicates that the employee is effectively cleansing the wound?

7 :
A client is being admitted to the unit with a varicella zoster virus infection. Which room should the charge nurse assign to the client?

8 :
A client undergoing chemotherapy has developed painful mouth sores. Which intervention should the nurse include in the plan of care to reduce the client's discomfort?

9 :
The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear glove?

10 :
The nurse is teaching a client how to use crutches. Which action performed by the client demonstrates to the nurse a correct understanding of how to use the crutches?

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RN HESI Fundamentals Exam 3

No.

1 : The nurse determines that a client's oxygen flow meter is set at 1.5 L/minute, the nasal cannula is in place in the client's nares, and the oxygen tubing is disconnected from the flow meter. Which action would the nurse implement?

2 : The perioperative nurse is preparing the supplies for a surgery. After opening a sterile bottle of saline for irrigation, how should the nurse label the opened bottle? Select all that apply.

3 : The client is a 59-year-old female with cellulitis following a surgical procedure to repair a fracture 2 weeks ago. She has a history of seasonal allergies and

Answer Options

4 : While assessing a client's blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm Hg. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. Which action should the nurse implement next?

5 : A client with hypertension has a prescription for 8 mg of candesartan cilexetil PO daily. The medication is available in a 16 mg tablet. How many tablets should the nurse administer? (Enter numeric value only, rounded to the tenth.)

6 : The charge nurse is observing a new graduate's performance of wound care. Which technique indicates that the employee is effectively cleansing the wound?

7 : A client is being admitted to the unit with a varicella zoster virus infection. Which room should the charge nurse assign to the client?

8 : A client undergoing chemotherapy has developed painful mouth sores. Which intervention should the nurse include in the plan of care to reduce the client's discomfort?

9 : The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear glove?

10 : The nurse is teaching a client how to use crutches. Which action performed by the client demonstrates to the nurse a correct understanding of how to use the crutches?

1 :
The nurse determines that a client's oxygen flow meter is set at 1.5 L/minute, the nasal cannula is in place in the client's nares, and the oxygen tubing is disconnected from the flow meter. Which action would the nurse implement?

2 :
The perioperative nurse is preparing the supplies for a surgery. After opening a sterile bottle of saline for irrigation, how should the nurse label the opened bottle? Select all that apply.

3 :
The client is a 59-year-old female with cellulitis following a surgical procedure to repair a fracture 2 weeks ago. She has a history of seasonal allergies and

4 :
While assessing a client's blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm Hg. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. Which action should the nurse implement next?

5 :
A client with hypertension has a prescription for 8 mg of candesartan cilexetil PO daily. The medication is available in a 16 mg tablet. How many tablets should the nurse administer? (Enter numeric value only, rounded to the tenth.)

6 :
The charge nurse is observing a new graduate's performance of wound care. Which technique indicates that the employee is effectively cleansing the wound?

7 :
A client is being admitted to the unit with a varicella zoster virus infection. Which room should the charge nurse assign to the client?

8 :
A client undergoing chemotherapy has developed painful mouth sores. Which intervention should the nurse include in the plan of care to reduce the client's discomfort?

9 :
The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear glove?

10 :
The nurse is teaching a client how to use crutches. Which action performed by the client demonstrates to the nurse a correct understanding of how to use the crutches?