Hesi fundamentals V1 questions with answers and rationales

Hesi fundamentals v1 questions with answers and rationale

1. A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved? a. Number of staff induced injury b. Client satisfaction survey c. Health care-associated infection rate. d. Rate of needle-stick injuries by nurse. Acrylic nails are known to carry loads of bacteria and increase the risk of healthcare-associated infections. Therefore, by banning the wearing of acrylic nails, you would expect the prevalence of healthcare-associated infections to decrease. Acrylic nails have nothing to do with staff induced injuries, needle-stick injuries, or patient satisfaction scores. 2. Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A) Aspirating gastric contents to assure a pH value of 4 or less. This is a method used to determine proper placement of NG tubing, but not the most accurate. B) Hearing air pass in the stomach after injecting air into the tubing. This is a method used to determine proper placement of NG tubing, but not the most accurate. C) Examining a chest x-ray obtained after the tubing was inserted. After placing an NG-tube, the placement of the tube is confirmed via x-ray since it is the most accurate way to ensure the tube has not been placed in the lungs, which would pose an aspiration risk. D) Checking the remaining length of tubing to ensure that the correct length was inserted. This is not an indicator of proper placement. You could very well be in a lung. 3. The father of an 11-year-old client reports to the nurse that the client has been “wetting the bed” since the passing of his mother and is concerned. Which action is most important for the nurse to enact? A. Reassure the father that it is normal for a pre-teen to wet the bed during puberty B. Inform the fathe entally delayed C. Inform the father that it is most important to let the son know that nocturnal emissions are normal after trauma D. Refer the father and the client to a psychologist It is common for adolescents to regress in their biological progression after experiencing a severe trauma, like losing a parent, sibling, or friend. While uncomfortable for the adolescent and parent, it is nothing to be concerned for. Often times, as the patient grieves or comes to terms with the trauma, the nocturnal emissions will cease. 4. The nurse explains to an older adult male the procedure for collecting a 24-hour urine specimen for creatinine clearance. Which action is most important for the nurse to include in their care plan for the shift?