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HESI Fundamentals Practice Test An adult is now alert and oriented following abdominal surgery. What position is most appropriate for the client?
- Semi-Fowler's
- Prone
- Supine
- Sim's
(Ans- A This position allows for greater thoracic expansion and puts less pressure on the suture line
Following a craniotomy, the nurse positioned a client in low fowler's for which reason?
- To promote comfort
- To promote drainage from operation site
- To promote thoracic expansion
- To prevent circulatory overload
(Ans- B
The nurse is caring for a woman who had a CVA and has right-sided hemiplegia.Which action is least appropriate?
- Performing ROM exercise when bathing her
- Changing her position every two hours
- Suctioning the client supine and pulling the bed sheets tightly across her feet
- Placing her in the prone position for one hour three times a day
(Ans- C The sheets should not be drawn tightly across the feet as this may cause foot drop
The nurse is to help their client with right-sided hemiplegia get up into the wheelchair. How should the nurse place the wheelchair?
- On the left side of the bed facing the foot of the bed
- On the right side of the bed facing the head of the bed
- Perpendicular to the bed on the right side 1 / 3
- Facing the bed in the left side of the bed
(Ans- A The client can then stand on the unaffected foot and pivot to sit down
When caring for a client in hemorrhagic shock, how should the nurse position the client?
- Flat in bed with legs elevated
- Flat in bed
- Trendelenburg position
- Semi-Fowler's position
(Ans- A
Mr. Landon is to have a tracheostomy performed. What is the top nursing priority?
- Shave the neck
- Establish a means of communication
- Insert a Foley catheter
- Start an IV
(Ans- B
Mr. Landon is to have a tracheostomy performed. Which nursing action is essential during tracheal suctioning?
- Using a lubricant such as petroleum jelly
- Administering 100% oxygen before and after suctioning
- Making sure that the suction catheter is open or on during insertion
- Assisting the client to assume a supine position during suctioning
(Ans- B--To prevent hypoxia
Mr. Landon is to have a tracheostomy performed. Which of the following actions is most appropriate for the nurse to take when suctioning the tracheostomy?
- Use sterile tube each time and suction for 30 seconds
- Use sterile technique and turn the suction off as the catheter is introduced
- Use clean technique and suction for 10 seconds
- Discard the catheter at the end of every shift
- / 3
(Ans- B
Mr. Landon is to have a tracheostomy performed. While the nurse is suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?
- Suction deeper to pick up secretions
- Gently withdraw suction tubing to allow suction or coughing out of mucous
- Remove the suction as quickly as possible
- Put the suction in and out several times to pick up secretions
(Ans- D
During the suctioning of a tracheostomy tube, the catheter appears to attach to the tracheal walls and creates a pulling sensation. What is the best action for the nurse to take?
- Release the suction by opening the vent
- Continue suctioning to remove obstruction
- Increase the pressure
- Suction deeper
(Ans- A
Warm compresses are ordered for an open wound. Which action is appropriate for the nurse?
- Use sterile technique when applying the dressing
- Leave the compresses on the area continuously, pouring warm solution on the
- Alternate warm compressed with cold ones
- Apply wet dressing, cover with dry dressing
area when it cools down
(Ans- A
The day after surgery in which a colostomy was performed, the client says "I know the doctor did not really do a colostomy". The nurse understands that the client is in an early stage of adjustment to the diagnosis or surgery, with nursing action is indicated at this time?
- Agree with the client until he is ready to accept the colostomy
- Say "It must be difficult to have this kind of surgery"
- Force the client to look at his colostomy
- / 3
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