HESI Fundamentals - Set 3 - Part 2

Correct Answer: At least every two hours throughout shift

Repositioning at least every two hours redistributes pressure off bony prominences and prevents tissue ischemia. The schedule is paired with skin checks and pressure-redistribution surfaces as the cornerstone of prevention in immobile patients. Option a is incorrect because Once during a twelve-hour shift leaves the patient under prolonged pressure that exceeds tissue tolerance. Pressure injuries can develop within hours when blood flow is interrupted by sustained body weight on bony areas. Option b is incorrect because Waiting for the patient to ask is unsafe because many patients cannot voice discomfort early. The nurse turns proactively rather than reactively, especially for patients with cognitive change or sedation. Option c is incorrect because Repositioning only at the start of each shift leaves long stretches without movement. The two-hour standard exists because tissue tolerance fails sooner than that, especially for patients with poor perfusion or low body mass.

Correct Answer: Stage one with intact skin and erythema

Stage one pressure injury features intact skin with non-blanchable erythema. The skin is not yet broken but the underlying tissue has been injured, and prevention measures must be intensified to stop further damage. Option a is incorrect because Stage two involves partial thickness skin loss with a shallow open wound or blister. The case described still has intact skin, which rules out stage two and points toward an earlier classification. Option c is incorrect because Stage three involves full-thickness skin loss with subcutaneous tissue visible. The presentation does not match an open wound at all, since the skin remains intact in this case so far. Option d is incorrect because Stage four involves full-thickness loss with exposed bone, tendon, or muscle. Nothing in the description matches that level of damage; the skin is closed and only redness is currently observed at the heel.

Correct Answer: High-protein, calorie-rich foods with vitamins

High-protein, calorie-rich foods with adequate vitamins support tissue repair and granulation. The nurse may collaborate with a dietitian to add supplements and ensure the patient meets the metabolic demands of healing. Option a is incorrect because A high-fat, low-protein liquid diet does not provide the amino acids needed for tissue repair. Wounds heal poorly when protein intake is inadequate, and pure liquid fat provides calories without the necessary building blocks. Option b is incorrect because Carbohydrate-only diets give energy but no protein for repair. Wound healing requires building blocks beyond simple sugars, and a deficient diet slows or stalls progress at every stage of repair. Option d is incorrect because Severely restricted diets worsen healing and accelerate weight loss. Pressure injury patients usually need increased intake rather than restriction, since the metabolic demands of healing add to baseline nutritional needs every day.

Correct Answer: Hydrocolloid dressing for moist environment

Hydrocolloid dressings maintain a moist wound environment and protect granulation tissue. They can stay in place several days, reducing dressing-change trauma and supporting epithelialization in clean wounds with minimal drainage at this stage. Option b is incorrect because Dry gauze packing changed every hour disrupts new tissue and pulls away healing cells with each change. Frequent removal also dries the wound bed, which slows healing rather than supporting it during recovery. Option c is incorrect because Wet-to-dry dressings serve to debride wounds with dead tissue, not to support clean granulating wounds. Using them on healthy tissue removes new cells and is no longer recommended for granulating bases. Option d is incorrect because A tight elastic wrap pressed against a clean granulating wound damages tissue. Pressure dressings have specific indications, such as vascular compression, but they are not used routinely on a clean granulating wound.

Correct Answer: Patient at high risk needing aggressive prevention

A Braden score of twelve places the patient at high risk for pressure injury and triggers aggressive prevention. The nurse layers turning, surface, nutrition, moisture, and friction measures throughout the day on the unit. Option a is incorrect because No risk corresponds to high scores, not twelve. The score described falls in the high-risk band, and treating the patient as no-risk would skip the layered prevention measures that are clinically required here. Option b is incorrect because Low risk corresponds to higher Braden scores, typically near fifteen to eighteen. A score of twelve falls below that band, so routine measures alone are insufficient and additional interventions must be added to the plan. Option c is incorrect because Very low risk corresponds to the highest Braden scores around eighteen or above. Twelve sits well below that range, marking the patient as high risk and not very low risk for pressure injury formation.

Correct Answer: Approximately twenty-eight percent oxygen delivered

At two liters per minute, the nasal cannula delivers about twenty-eight percent oxygen. The concentration rises roughly four percent per liter, with practical use up to about six liters before drying becomes a concern. Option a is incorrect because Ten percent oxygen is below room air, which is twenty-one percent. Nasal cannula adds oxygen to inspired air rather than reducing it, so the option misrepresents the function of the device entirely. Option b is incorrect because Fifty percent oxygen exceeds what a nasal cannula can deliver. Higher concentrations require partial rebreather, non-rebreather, Venturi, or high-flow nasal cannula systems built for that level of delivery instead. Option d is incorrect because Ninety percent oxygen requires a non-rebreather mask with reservoir bag at high flow. A standard nasal cannula at two liters does not approach that concentration in any clinical scenario.

Correct Answer: Set flow to keep reservoir bag inflated

Flow must be high enough to keep the reservoir bag inflated through inhalation. A bag that empties means the patient is rebreathing exhaled air, which defeats the purpose of the high-concentration mask. Option b is incorrect because Allowing the bag to fully collapse means the patient inhales mostly exhaled gas instead of fresh oxygen. The setup defeats the high-concentration design and can lead to worsening hypoxia and carbon dioxide retention. Option c is incorrect because One liter per minute is far below the flow needed to keep the reservoir inflated. The mask requires a flow that fills and maintains the bag throughout the breathing cycle of the patient. Option d is incorrect because Opening all side ports lets room air dilute the oxygen and breaks the seal that traps high concentrations. The mask design depends on closed side ports during inhalation to deliver near-pure oxygen to the patient.

Correct Answer: Precise fixed oxygen concentration delivery

The Venturi mask uses interchangeable adapters to deliver a precise fixed oxygen concentration. The control matters in chronic obstructive pulmonary disease, where excessive oxygen can blunt the hypoxic drive and worsen carbon dioxide retention. Option a is incorrect because The Venturi mask does not deliver the highest concentration; non-rebreather masks reach higher levels. The Venturi system trades concentration for precision, which is exactly what is needed for the chronic obstructive disease patient. Option c is incorrect because Humidification is not the defining feature of a Venturi mask, and humidification can be added to many oxygen systems. The precise concentration delivery is the unique advantage that distinguishes Venturi from other masks. Option d is incorrect because Oxygen saturation monitoring is still required regardless of which delivery device is used. No oxygen device removes the need for monitoring, since titration depends on the patient's response to therapy

Correct Answer: Avoid open flames and smoking near oxygen

Open flames and smoking must be avoided near oxygen because the gas accelerates combustion. The teaching includes posting no-smoking signs, keeping the source away from the kitchen, and removing matches and lighters nearby. Option a is incorrect because Smoking ten feet away is still a fire risk, since clothing and surfaces retain residual oxygen and embers can travel. The standard guidance is no smoking around the patient or oxygen equipment. Option b is incorrect because Candles produce open flames that can ignite an oxygen-rich environment regardless of open windows. Ventilation does not eliminate the danger, and any open flame is incompatible with continuous home oxygen therapy nearby. Option c is incorrect because Cooking on a gas stove while wearing oxygen tubing creates a serious fire risk. The flame and the oxygen-rich tubing combine into an ignition hazard that has caused severe burns and house fires.

Correct Answer: Humidification reduces drying of mucous membranes

Humidification reduces drying of nasal and pharyngeal mucous membranes during higher-flow oxygen. The added moisture protects tissue, prevents bleeding, and improves comfort during prolonged therapy at flow rates above four liters per minute. Option a is incorrect because Humidification does not reduce oxygen concentration in any meaningful way. The added water vapor sits in the gas mixture without displacing the oxygen that the patient receives at the prescribed flow rate. Option b is incorrect because Dry oxygen actually causes nosebleeds rather than preventing them, especially at higher flow rates. The mucous membranes dry, crack, and bleed when high-flow gas is delivered without adequate humidification over time. Option d is incorrect because Humidification systems can introduce infection if not maintained properly, but with proper care infection risk is low. The benefit of preventing dryness usually outweighs the manageable risk in most clinical scenarios.

Correct Answer: Increased work of breathing and distress

Use of neck and shoulder muscles with retractions signals increased work of breathing and respiratory distress. The patient is recruiting accessory muscles because the diaphragm and intercostals alone cannot meet the demand for ventilation. Option b is incorrect because Normal resting breathing does not require accessory muscles. The presence of these muscle activations is a clear sign that the breathing effort has escalated beyond baseline and warrants prompt assessment and intervention. Option c is incorrect because Improved oxygenation would lessen, not increase, the use of accessory muscles. The findings here point to worsening status that must be addressed quickly rather than to clinical improvement during the encounter. Option d is incorrect because Decreased respiratory effort is the opposite of what is being seen at the bedside. The patient is working harder, not less, and the description of accessory muscle use directly contradicts a relaxed easy breathing pattern.

Correct Answer: Air through narrowed lower airways

Wheezing comes from air moving through narrowed lower airways, often during expiration. The narrowing reflects bronchospasm, mucosal swelling, or secretions, all of which can occur in asthma exacerbations and respond to bronchodilators. Option a is incorrect because Air moving over fluid in the alveoli produces crackles, not wheezes. The two sounds reflect different processes; crackles signal fluid or atelectasis, while wheezes signal narrowed conducting airways at the bronchial level. Option b is incorrect because Pleural surfaces rubbing together produce a friction rub heard during inspiration and expiration. The sound is grating rather than musical, and the location is often focal rather than diffuse like wheeze. Option c is incorrect because Stridor describes a high-pitched inspiratory sound from upper airway obstruction. The classification is separate from wheeze, which is a lower-airway phenomenon usually heard predominantly during expiration in asthma.

Correct Answer: Collect early morning deep cough sample

Early morning samples are richest because secretions accumulate overnight in the airways. The patient takes a deep breath and coughs forcefully into the sterile container, and oral rinse before collection reduces saliva contamination. Option a is incorrect because Collecting after an antibiotic dose can suppress bacterial growth in the culture and make the result misleading. The specimen is best obtained before antibiotics start when possible, especially when the result will guide therapy. Option b is incorrect because Saliva from oral swabs is not equivalent to sputum from the lower airways. Cultures done on saliva produce results that reflect mouth flora rather than the pathogens causing pneumonia in the lungs. Option d is incorrect because Collecting during meals risks contamination from food and saliva. The specimen is collected in a quiet moment with attention to deep cough, and meal times do not match the typical preferred collection window.

Correct Answer: Pulse ox cannot distinguish carboxyhemoglobin from oxyhemoglobin

Standard pulse oximeters cannot distinguish carboxyhemoglobin from oxyhemoglobin and read falsely high. Cooximetry from arterial blood is needed to identify carbon monoxide poisoning, since the patient may be hypoxic despite a reassuring oximeter value. Option b is incorrect because The device is less accurate, not more, during carbon monoxide exposure. The reading does not reflect tissue oxygenation because the bound carbon monoxide blocks the binding sites without changing the device's measurement signal. Option c is incorrect because The pulse oximeter does not signal true hypoxia in carbon monoxide poisoning, since the displayed value remains high while tissue oxygen delivery is impaired. The clinical picture matters more than the number here. Option d is incorrect because Values do not triple in poisoning; they typically read normal or near normal. The deceptive normalcy of the reading is precisely what makes the device unreliable in this specific clinical scenario in care.

Correct Answer: Hypoventilation needing prompt nursing assessment

A rising end-tidal carbon dioxide reflects hypoventilation, often from opioid-induced respiratory depression. The nurse assesses respiratory rate, depth, level of consciousness, and prepares to escalate care or administer reversal as indicated. Option a is incorrect because Hyperventilation lowers end-tidal carbon dioxide rather than raising it. Adding more opioid in this scenario would deepen ventilatory depression and worsen the situation rather than addressing the developing concern at the bedside. Option c is incorrect because A rising end-tidal carbon dioxide is not a normal stable pattern. The trend signals a developing problem that needs prompt evaluation rather than reassurance about ongoing stability of the patient's ventilation. Option d is incorrect because Equipment malfunction is possible but unlikely to fit the clinical context of opioid use. The nurse should treat the trend as physiologic until proven otherwise and assess the patient before assuming a device error.

Correct Answer: Apply oxygen and elevate head of bed

Applying oxygen and elevating the head of the bed addresses oxygenation and ventilation. The interventions are independent nursing actions that improve gas exchange while the medical team initiates antibiotics and additional supportive measures during the early admission. Option a is incorrect because Discharge teaching is premature when the patient has just arrived with significant hypoxia. The nurse stabilizes the patient first, and education becomes appropriate later in the stay when condition has improved enough. Option b is incorrect because Long-term management teaching can wait until after acute symptoms are addressed. The patient cannot focus on learning while struggling for breath, so the timing must match readiness and clinical stability. Option c is incorrect because Encouraging rest is appropriate, but limiting all movement is not the priority intervention. The patient still benefits from upright positioning, deep breathing, and incentive spirometry to improve ventilation a

Correct Answer: Elevate head thirty to forty-five degrees

Elevating the head of the bed thirty to forty-five degrees reduces aspiration risk in ventilated patients. The bundle also includes daily sedation interruption, oral care with chlorhexidine, and assessment for extubation readiness. Option a is incorrect because Keeping the head flat increases aspiration risk and is contrary to bundle recommendations. Supine position allows gastric contents and secretions to enter the lower airway, raising the risk of pneumonia development quickly. Option b is incorrect because Oral care is a bundle element but happens more often than once per shift. Frequent oral care with antiseptic agents reduces the bacterial load that can be aspirated past the endotracheal tube cuff. Option d is incorrect because Daily sedation interruption is part of the bundle to assess weaning readiness, not stopped. Stopping the practice prolongs ventilation, increases pneumonia risk, and reverses the benefits the bundle is designed to provide.

Correct Answer: Receive recommended pneumococcal and flu vaccines

Pneumococcal and influenza vaccinations reduce the risk of pneumonia in older adults and those with chronic respiratory disease. The vaccines protect against common causative organisms and are part of standard preventive guidance for the population. Option b is incorrect because Avoiding all outdoor activity is unnecessary and harmful to overall health. The patient benefits from regular activity, fresh air, and social connection, and complete isolation produces deconditioning rather than infection prevention long term. Option c is incorrect because Daily antibiotics indefinitely as prevention promote resistance and adverse effects. Antibiotics are reserved for active infections under specific circumstances, and chronic prophylactic use is rarely indicated for the general adult population. Option d is incorrect because Limiting fluid intake worsens hydration and thickens secretions, making pneumonia more likely. Adequate hydration thins mucus and supports clearance, which is the opposit

Correct Answer: Inhale slowly and hold breath at top

The patient inhales slowly and deeply through the mouthpiece, then holds the breath at the top for several seconds. The technique opens alveoli and prevents atelectasis, which can progress to pneumonia after surgery. Option a is incorrect because Exhaling rapidly into the device defeats the inspiratory training purpose. The spirometer measures inhaled volume, and forceful exhalation does not produce the alveolar opening that the device is designed to encourage. Option b is incorrect because Coughing hard before each attempt does not improve performance and may exhaust the patient. Coughing can be part of pulmonary hygiene, but it is not the technique of incentive spirometry use specifically. Option c is incorrect because Holding the device upside down does not match the standard upright orientation. The piston design depends on gravity, and inverted use produces inaccurate or absent volume readings during attempts at the bedside.

Correct Answer: Confusion and decreased intake may signal pneumonia

In older adults, pneumonia may present as confusion, decreased intake, and only mild temperature elevation. The nurse considers infection in any older adult with new mental status change and assesses the lungs and oxygenation carefully. Option a is incorrect because Confusion and decreased intake do not rule out pneumonia; they often suggest it in older adults. Treating these as unrelated to infection delays diagnosis and lets the underlying process worsen during the stay. Option b is incorrect because Pneumonia in older adults frequently lacks high fever because immune response is blunted with age. Insisting on classic findings misses many cases, and lower thresholds for concern are appropriate in the population. Option d is incorrect because Productive cough is not required for the diagnosis, especially in older adults. Many present with subtle cough or no cough at all, while confusion and reduced function become the dominant cues instead.