HESI Fundamentals - Set 2 - Part 2

Correct Answer: Keep field within sight at all times

An unattended sterile field is considered contaminated, so the nurse keeps the field within sight until the procedure is complete. Turning the back or leaving the room invalidates sterility and forces the nurse to restart. Option a is incorrect because Reaching across a sterile field contaminates it because dust and skin cells from the arm shed onto the area below. The nurse approaches from the side and reaches around rather than over the field. Option b is incorrect because Lower portions of the drape that hang below waist level are considered non-sterile. The nurse cannot use any item that touched a low-hanging portion and must keep the field above the waist. Option c is incorrect because Items must remain at least one inch from the edge of the field, since the very edge is considered non-sterile. Two inches is even safer, but placement specifically must avoid the edge in either case.

Correct Answer: Wet field becomes contaminated by wicking

A wet sterile field is considered contaminated because moisture wicks pathogens up from the non-sterile surface below. The nurse must replace the drape and any items that have touched the wet portion before continuing. Option a is incorrect because Moisture has a major effect on sterility because water creates a continuous path for organisms to travel through. The classic principle of strikethrough contamination accounts for the wicking that turns wet drapes non-sterile. Option c is incorrect because Covering a wet field does not remove the contamination that has already occurred through wicking. The field cannot be salvaged once moisture has bridged sterile and non-sterile surfaces underneath the drape. Option d is incorrect because Drying the field with paper does not restore sterility, since the pathogens are now within the drape fibers. The drape must be replaced rather than dried, and the procedure resumed with new equipment.

Correct Answer: Touch only inside cuff with bare hand

In open-glove technique, the nurse touches only the inside cuff of the glove with the ungloved hand. Once one glove is on, the gloved hand touches only the outside of the second glove during donning. Option a is incorrect because Touching the outer glove surface with a bare hand contaminates the sterile exterior. The nurse must keep skin contact limited to the inside of the cuff during open-glove donning at every step here. Option b is incorrect because Gripping the fingertips of the glove with the bare hand contaminates the part that will touch the patient. The nurse must instead pinch the inside cuff and pull the glove onto the dominant hand. Option d is incorrect because Wet hands snag the glove and can also wick contaminants through the material. Hands must be fully dry after hand hygiene before donning gloves to maintain sterility and avoid skin irritation later.

Correct Answer: Turning back on field even briefly

Turning the back on a sterile field contaminates it, even briefly, because the field is no longer monitored. Out-of-sight equals out-of-sterile, and the nurse must remain facing and watching the field at all times. Option b is incorrect because Holding sterile items above the waist preserves sterility because anything below waist level is considered non-sterile. The action is correct technique, not a break, since visibility and elevation are both maintained. Option c is incorrect because Opening packages with the sterile inner surfaces facing up keeps the contents sterile during transfer. The technique is recommended rather than incorrect, and the wrapper edges fold away from the contents. Option d is incorrect because Pouring solution carefully without splashing keeps the tray dry and avoids strikethrough contamination. The nurse demonstrates correct technique here rather than committing a break in sterility during fluid handling.

Correct Answer: Replace contaminated items and restart setup

Replacing the contaminated drape and any affected items and restarting the sterile setup is the only safe recovery. Sterility cannot be restored at the bedside, and continuing with contaminated equipment risks infection at the procedure site. Option a is incorrect because Adding disinfectant during a sterile procedure does not restore sterility and may damage tissue. Disinfectant solutions and antiseptic preparations are not interchangeable, and the procedure cannot proceed with contaminated equipment under any circumstance. Option b is incorrect because Covering the contaminated area with a towel does not address pathogens already on the drape. The hidden contamination remains a risk and the procedure must be restarted with new sterile materials at the bedside. Option c is incorrect because Skipping the procedure altogether is generally not necessary; the nurse can rebuild the sterile field rather than abandon care. The patient still needs the planned procedure, just with new sterile

Correct Answer: Encourage fluids and offer light cover

Encouraging fluids supports increased metabolic demand during fever and replaces insensible losses. A light cover supports patient comfort while allowing heat dissipation, and the nurse continues to monitor the trend over the next hour. Option a is incorrect because Aggressive ice packs cause shivering, which raises core temperature further as muscles generate heat. The intervention is also uncomfortable and unnecessary for a moderate fever in an otherwise stable adult patient. Option b is incorrect because A cold sponge bath also triggers shivering and undoes any cooling effect. Tepid water is sometimes used, but fluids and a light cover usually suffice for moderate fever in a stable adult. Option d is incorrect because Bundling the patient in warm blankets traps heat and elevates the temperature further. The intervention is the opposite of what the patient needs; air circulation should be promoted, not blocked through heavy layers.

Correct Answer: Tympanic with proper ear canal alignment

Tympanic temperature is fast, well tolerated by confused patients, and accurate when the ear canal is properly aligned. The nurse pulls the pinna up and back for adults to straighten the canal during the reading. Option b is incorrect because Oral temperature taken over a hot beverage cup is invalid because the local temperature has been altered. The nurse should wait fifteen to thirty minutes after hot or cold drinks before taking an oral reading. Option c is incorrect because Axillary readings tend to underestimate core temperature and require good probe contact for accuracy. The site is generally a backup rather than first choice when other reliable sites are available for the patient. Option d is incorrect because Oral readings with the mouth open are inaccurate because room air cools the probe area. Mouth-breathing patients are poor candidates for oral readings, which is why an alternative route is being chosen here.

Correct Answer: Thermoregulatory failure with environmental heat

Hyperthermia results from thermoregulatory failure under environmental heat, not a reset of the hypothalamic set point. Cooling is appropriate because the body is unable to dissipate heat fast enough on its own. Option a is incorrect because A reset hypothalamic set point describes fever, where the body actively maintains a higher core temperature. The mechanism comes from inflammatory mediators, not the failure of thermoregulation seen in environmental heat exposure. Option c is incorrect because Cytokine-mediated reset of the temperature center describes fever, not hyperthermia. Cytokines are produced as part of an immune response and cause the hypothalamus to push for a higher target temperature. Option d is incorrect because Pyrogen exposure from bacterial infection produces fever rather than hyperthermia. The mechanism for the second patient is environmental heat, not a circulating pyrogen from an infectious source within the body.

Correct Answer: Remove wet clothing and apply warm blankets

Removing wet clothing and applying warm blankets begins gentle external rewarming. Wet fabric continues to draw heat from the body, so the first move is to dry the patient and add insulating layers immediately. Option a is incorrect because Vigorous walking is unsafe because hypothermia impairs coordination and risks cardiac dysrhythmia. The patient needs gradual rewarming with rest, not exertion, until core temperature has been restored to normal range. Option b is incorrect because A cool tub of water would worsen hypothermia by withdrawing more body heat. Warm tub immersion has limited bedside use and any rewarming method must add heat, not remove it from the patient's body. Option c is incorrect because Withholding blankets allows continued heat loss and ignores the obvious priority of rewarming. The patient is hypothermic, not febrile, and needs added warmth rather than caution about excess heat retention.

Correct Answer: May signal serious infection in older adults

Older adults often have lower baseline temperatures, so a reading of one hundred point four can signal serious infection. The nurse takes the elevation seriously and assesses for sepsis cues like confusion, fatigue, and poor intake. Option a is incorrect because A reading of one hundred point four is not within normal range for most adults and especially raises concern in older adults. Treating the value as normal can delay recognition of an underlying infection. Option b is incorrect because Mild dehydration may produce a slight elevation but does not explain mental fogginess in this scenario. The nurse must consider infection in any older adult with a temperature change and altered mental status. Option d is incorrect because Treating one hundred point four as below fever range underestimates the significance in older adults. The threshold for concern in this population is lower because immune response is blunted with age.

Correct Answer: Stethoscope at fifth intercostal space midclavicular

The apical pulse is auscultated at the fifth intercostal space at the midclavicular line, where the apex of the heart lies. The nurse listens for one full minute to confirm rate, rhythm, and any irregularity. Option b is incorrect because Radial palpation is not the apical pulse and may miss irregular beats from atrial fibrillation. Apical auscultation is required for medications like digoxin to count beats accurately at the heart. Option c is incorrect because Carotid palpation is used in emergencies and not for routine apical pulse counting before medications. The carotid site can also stimulate the vagus nerve and slow the rate during palpation. Option d is incorrect because The right second intercostal space is the aortic auscultation area and not the apex location. The apex is on the left side of the chest at the fifth intercostal space at midclavicular line.

Correct Answer: Notify provider and place on monitor

Symptomatic bradycardia with dizziness and cool extremities needs provider notification and continuous cardiac monitoring. The findings suggest decreased perfusion, and orders for medication adjustment or further workup may be needed quickly. Option a is incorrect because Documenting alone misses the urgency of symptomatic bradycardia with hypotension and dizziness. The nurse must escalate care because the patient's perfusion is compromised and could deteriorate without intervention. Option b is incorrect because Encouraging the patient to walk around the unit is unsafe with new dizziness and decreased perfusion. The patient should rest and remain monitored until the cause of the slow heart rate has been addressed. Option c is incorrect because Restarting held cardiac medications without provider input could worsen bradycardia and hypotension. Many cardiac medications slow the heart, and the nurse must consult the provider rather than acting independently here.

Correct Answer: Lying, then sitting, then standing with timing

Orthostatic vital signs are taken lying, then sitting, then standing, with brief delays between positions. A drop of twenty millimeters of mercury systolic or ten diastolic, or pulse rise of twenty, is significant. Option a is incorrect because Starting with standing reverses the sequence and misses the lying baseline needed to compare. Without that baseline, the nurse cannot identify the drop that defines orthostatic hypotension during the assessment process. Option b is incorrect because Sitting before measuring lying loses the resting reference point. Lying must be the first position so that subsequent readings can be compared with the patient at full rest in horizontal position. Option d is incorrect because Random positions and inconsistent timing make the measurement unreliable. Standardized sequence and pacing are needed for orthostatic vital signs to detect the drop in blood pressure on position change correctly.

Correct Answer: Use a larger cuff fitting arm

A cuff that is too small produces a falsely high blood pressure reading. The nurse should select a larger cuff that fits the arm circumference correctly to ensure the measurement reflects actual pressure. Option b is incorrect because Using the same regular cuff again repeats the original error of size mismatch. The reading will continue to be falsely elevated and could lead to unnecessary medication changes if reported uncritically to the team. Option c is incorrect because A pediatric cuff is even smaller and would worsen the falsely elevated reading. Cuff selection must match arm circumference; smaller cuffs are not appropriate for adult arms with larger circumference at all. Option d is incorrect because Skipping the recheck means accepting an inaccurate value that could trigger unwarranted treatment. The nurse must verify the reading with the proper cuff size before passing on potentially misleading information.

Correct Answer: Phase five when sounds disappear in adults

In adults, the diastolic blood pressure is read at phase five, when Korotkoff sounds disappear during cuff deflation. Phase one marks the systolic reading, when the first clear tapping sound is heard above the cuff. Option a is incorrect because Phase one represents the systolic blood pressure, not the diastolic reading. The first sound heard reflects when arterial flow restarts beneath the deflating cuff, marking the upper number rather than the lower one. Option c is incorrect because Phase three is a mid-deflation increase in sound intensity and not a recorded number. The nurse documents systolic and diastolic values, not phases in between, which are heard but not used in reporting. Option d is incorrect because Phase two has swooshing or murmur-like sounds and is also not a documented value. The recorded blood pressure uses phases one and five in adults, which mark systolic and diastolic respectively at the artery.

Correct Answer: Count chest rise quietly without telling

Counting chest rise quietly without telling the patient prevents conscious alteration of the breathing rate. Patients often slow or speed up when they know respirations are being measured, which biases the recorded rate. Option a is incorrect because Telling the patient to breathe normally draws attention to breathing and changes the natural rate. The nurse should not announce the assessment, since awareness alters the very behavior being measured at the bedside. Option b is incorrect because Placing a sensor on the lip is unnecessary for routine bedside respiratory rate measurement. Visual counting of chest rise gives a reliable rate when the patient does not know the count is happening. Option c is incorrect because Asking the patient to follow the nurse's breathing imposes a rate rather than measuring the actual one. The number gathered will reflect the demonstration rather than the patient's true respiratory pattern at all.

Correct Answer: Cold limbs and polish reduce signal quality

Cold extremities, dark nail polish, and motion all reduce signal quality on a pulse oximeter. The nurse warms the digit, removes polish if possible, or moves the probe to another site for an accurate reading. Option a is incorrect because Pulse oximeter accuracy is affected by perfusion, polish, motion, light interference, and other factors. Treating the device as foolproof leads to false reassurance or false alarm and can result in poor decisions. Option b is incorrect because Cold limbs reduce peripheral perfusion and cause inaccurate or low readings. The probe relies on pulsatile blood flow through the digit, so any condition that reduces flow weakens the signal noticeably. Option d is incorrect because Dark nail polish absorbs the light used by the oximeter and produces falsely low readings. Removing the polish, applying the probe sideways, or using the toe or earlobe site improves accuracy reliably.

Correct Answer: Assess oxygen saturation and lung sounds

A respiratory rate of twenty-eight in a chronic obstructive pulmonary disease patient with new fever raises concern. Assessing oxygen saturation and lung sounds quickly clarifies whether oxygenation is failing and whether escalation is needed. Option b is incorrect because Documenting alone delays care for a patient who may be in early respiratory distress. The nurse must gather more data with focused assessment before deciding whether the value reflects baseline anxiety or worsening illness. Option c is incorrect because Reassurance to slow breathing addresses anxiety only, not a possible underlying physiologic cause. The nurse must rule out hypoxia and infection before assuming the cause is purely behavioral and not medical. Option d is incorrect because Waiting an hour leaves the patient at potential risk for further decline without information. The nurse cannot defer assessment when the rate is high in a patient with respiratory disease and recent fever.

Correct Answer: Respiratory acidosis without metabolic compensation

The low pH and high carbon dioxide define respiratory acidosis. The bicarbonate sits within the normal range, indicating that no metabolic compensation has occurred yet, so the imbalance is uncompensated at this point. Option a is incorrect because Metabolic alkalosis would show a high pH and high bicarbonate. Neither pattern is present here, since the pH is acidic and the bicarbonate sits at the bottom of the normal reference range only. Option b is incorrect because Respiratory alkalosis would show a high pH and a low carbon dioxide. The pH and the carbon dioxide both move in the wrong directions for that diagnosis at this point in time. Option c is incorrect because Metabolic acidosis would show a low pH and low bicarbonate. The bicarbonate sits at twenty-four within the normal range, so the abnormality is respiratory rather than metabolic in origin here today.

Correct Answer: Opioid-induced respiratory depression needing reversal

Rising end-tidal carbon dioxide with falling rate and decreased arousability points to opioid-induced respiratory depression. The nurse calls for help, supports breathing, and prepares naloxone per protocol while continuing to monitor cardiopulmonary status. Option a is incorrect because Hyperventilation would show a falling rather than rising end-tidal carbon dioxide and a faster respiratory rate. Adding sedation in this scenario would deepen the depression and worsen the patient's situation immediately. Option b is incorrect because The trend is far from stable, since the carbon dioxide is rising and the rate has dropped. Routine documentation alone misses a developing emergency that requires immediate intervention by the team at the bedside. Option d is incorrect because Normal sleep does not produce a marked rise in end-tidal carbon dioxide and an inability to arouse. The pattern described is pathologic and reflects ventilatory failure rather than restful, healthy sleep in the