HESI Fundamentals - Set 3 - Part 3

Correct Answer: Perform abdominal thrusts on standing patient

Abdominal thrusts on a conscious choking adult drive air upward to expel the obstruction. The nurse stands behind the patient, makes a fist above the umbilicus, and delivers quick inward and upward thrusts. Option b is incorrect because Back slaps are not the standard response for adult conscious choking. The recommended action is abdominal thrusts, sometimes described as the Heimlich maneuver, until the object is expelled or the patient becomes unresponsive. Option c is incorrect because Waiting for the cough to clear the airway delays needed action when the patient cannot exchange air. The lack of effective cough is the cue that intervention is required immediately rather than continued observation. Option d is incorrect because Chest compressions are reserved for unresponsive patients without a pulse. A conscious patient is treated with abdominal thrusts; chest compressions begin only after the patient becomes unresponsive and pulseless during the event.

Correct Answer: Limit each suction pass to ten seconds

Each suction pass should last no longer than ten to fifteen seconds to limit hypoxia. The nurse applies suction only on withdrawal and hyperoxygenates the patient before and between passes to maintain saturation safely. Option a is incorrect because Continuous suction for thirty seconds causes significant hypoxia and damages mucosa. Short, controlled passes with adequate recovery between them are the standard for protecting the airway during the procedure used today. Option c is incorrect because Pushing the catheter against resistance traumatizes the airway and can cause bleeding. The nurse advances gently until resistance is met, then pulls back slightly before applying suction during withdrawal. Option d is incorrect because Hyperoxygenation between passes is part of the standard, not avoided. Skipping it leaves the patient hypoxic between passes and can cause significant desaturation, bradycardia, and other adverse effects on cardiac status.

Correct Answer: Air leak somewhere in the system

Continuous bubbling in the water seal chamber suggests an air leak somewhere in the system. The nurse traces the tubing for connection issues and notifies the provider, since the leak source must be identified and corrected. Option a is incorrect because Continuous bubbling is not the normal pattern; intermittent bubbling with respirations may be expected during initial drainage. The persistent pattern points to an abnormal air leak that warrants investigation, not reassurance about normal function. Option b is incorrect because Continuous bubbling does not indicate full healing or readiness for chest tube removal. Healing is suggested by absence of bubbling, decreased drainage, and clinical stability over time, not by an active leak in the system. Option c is incorrect because A clamped or non-draining system would not show continuous bubbling. The bubbling actually requires air movement through the chamber, which means the system is functioning rather than being completely blocked of

Correct Answer: Use sterile saline and gauze without fibers

Sterile saline with non-fibrous gauze cleans the stoma and inner cannula without leaving particles. Lint and cotton fibers can be inhaled into the airway and cause irritation, so the nurse uses approved supplies only. Option a is incorrect because Cotton balls are inappropriate because they shed fibers that can be aspirated. The nurse uses pre-cut tracheostomy gauze or sterile non-fibrous pads for cleaning around the stoma site every time. Option b is incorrect because Skipping inner cannula cleaning allows secretions to accumulate and obstruct the airway. The nurse cleans or replaces the inner cannula on a regular schedule to maintain a patent tracheostomy throughout the shift. Option d is incorrect because Reusing suction catheters multiple times raises infection risk in the lower airway. Suction catheters are typically single-use, and the nurse follows institutional policy on disposal between passes during care.

Correct Answer: Head-tilt chin-lift maneuver

Head-tilt chin-lift is the standard airway-opening maneuver when no spinal injury is suspected. The technique lifts the tongue away from the back of the throat and opens the upper airway for breathing or rescue ventilation. Option b is incorrect because A head turn to the side does not open the airway and can complicate further care. The maneuver is not standard for airway opening, and obstructed breathing requires the proven head-tilt technique instead. Option c is incorrect because Pressing the chin against the chest closes rather than opens the airway. The mechanism causes obstruction by pushing the tongue further back and folding the upper airway downward against the larynx. Option d is incorrect because Heavy pressure on the neck can cause vascular and airway injury. Standard airway maneuvers use gentle support of the jaw and head, not forceful neck pressure, and may risk severe harm.

Correct Answer: Stop infusion and prepare epinephrine

Stopping the infusion removes ongoing exposure, and epinephrine is the first-line treatment for anaphylaxis. The nurse maintains airway, applies oxygen, and prepares additional medications and equipment as the team responds to the emergency. Option a is incorrect because Documenting the reaction matters but never replaces immediate action. The nurse must intervene to protect airway and circulation, and charting follows once the patient has been stabilized through emergency medications and support. Option b is incorrect because Encouraging fluids cannot reverse a systemic allergic reaction. The patient has airway swelling and circulatory compromise; oral hydration is unsafe and irrelevant during the acute event that is unfolding right now. Option c is incorrect because A cool compress to the face does not address airway compromise or hypotension. Topical comfort measures have no role in treating the systemic allergic reaction, which requires immediate medication administration.

Correct Answer: Target eighty-eight to ninety-two percent

Many patients with chronic obstructive pulmonary disease are targeted at eighty-eight to ninety-two percent saturation. The range supports oxygenation while avoiding the suppression of hypoxic drive that can occur with higher oxygen levels. Option a is incorrect because Targeting one hundred percent in chronic obstructive pulmonary disease patients can blunt hypoxic drive. The patient can develop carbon dioxide retention and worsening ventilation when oxygen is given without titration to a safer goal. Option b is incorrect because Sixty percent saturation indicates severe hypoxia and is not a target. The level represents significant tissue oxygen deprivation, and the nurse must work to keep the patient well above that range during therapy. Option d is incorrect because Seventy percent saturation also indicates dangerous hypoxia. The body cannot meet metabolic demand at that level, so the value is never an acceptable target for any patient under any condition.

Correct Answer: Green zone is good control, continue plan

Green zone indicates good asthma control and continuation of the current plan. Yellow zone indicates a flare and triggers rescue medication, while red zone indicates an emergency and prompts urgent care or rescue inhaler use. Option b is incorrect because Green zone is the safe range, not an emergency. The action plan uses traffic-light colors to prompt different responses, and treating green as urgent misreads the system entirely and wastes urgent resources. Option c is incorrect because Red zone signals the most severe symptoms and is an emergency. Stopping medications during a red-zone event would be dangerous; the patient uses rescue medication and seeks emergency evaluation immediately during the event. Option d is incorrect because Yellow zone signals worsening asthma that needs prompt action with rescue medication. Doing nothing during a yellow-zone event can allow progression to a red-zone emergency that is harder to control later.

Correct Answer: Offer counseling plus pharmacologic support

Counseling combined with nicotine replacement or other pharmacologic options doubles or triples cessation success. The nurse uses the five A's of ask, advise, assess, assist, and arrange to support each step of quitting. Option a is incorrect because Telling the patient to quit alone with no support has lower success rates. Most patients need both behavioral and pharmacologic help to quit successfully, and abandoning them to do it alone is unlikely to work. Option c is incorrect because Avoiding the topic misses an important teachable moment when motivation is high. The diagnosis itself often opens the door to honest discussion, and the nurse should engage rather than retreat from the conversation. Option d is incorrect because Recommending only herbal remedies provides limited evidence-based support for cessation. The nurse should mention proven options like nicotine replacement, varenicline, and bupropion as part of a complete and effective plan.

Correct Answer: Ventilation impaired while perfusion continues

In pneumonia, alveoli filled with fluid receive blood flow but cannot ventilate. The mismatch between continued perfusion and impaired ventilation causes hypoxemia despite supplemental oxygen, since the affected areas cannot exchange gas effectively. Option a is incorrect because Equal ventilation and perfusion describes a normal lung, not a pneumonia state. The condition specifically disrupts the matching of air and blood flow, and equal distribution would not produce the hypoxia seen here. Option b is incorrect because If both ventilation and perfusion were fully absent, no gas exchange would occur and the patient would die. The pneumonia scenario continues to involve some perfusion despite impaired ventilation in the affected area. Option c is incorrect because Increased ventilation and perfusion causing oxygen excess does not describe pneumonia. The disease state reduces ventilation to affected lung regions while perfusion persists, producing the classic mismatch and hypoxia in pat