2019 Hesi Fundamentals 47 Q&A PDF

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2019 HESI FUNDAMENTALS RN 47 TEST BANK Q /A

1. Wheezing is often associated with asthma- assess breathing patterns and learn about any precipitating factors that caused the onset of the wheezing 2. A male client with limited mobility is discharged with home health services. When the home health nurse arrives, the client asks what he does for the swelling in his leg. Which should the nurse implement?  -instruct the client to flex both of his feet several times a day 3. A client at an outpatient clinic submits a clean-catch midstream urine specimen for routine urinalysis. In later review of the client’s medical record, which data indicates to the nurse that the specimen collection should be repeated?  -the urine specimen shows multiple organisms in low colony counts Rationale: *often indicates that a contaminated specimen was obtained 4. During the admission assessment of a terminally ill male client, the client states that he is an agnostic. What is the best nursing action in response to this statement?  -document the statement in the client’s spiritual assessment 5. The nurse observes a newly admitted older adult female take short stems and walk very slowly while pushing a walker in front of her. What action should the nurse take in response to these observations?  -complete a full fall risk assessment of the client 6. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital signs should the nurse obtain first?  -respiratory rate Rationale: *cyanosis is a bluish discoloration, an indication of hypoxemia 7. A middle-aged male client tells the nurse that two weeks ago, he began exercising four times a week to lose weight and to help him sleep better. He states that it still takes him an hour to fall asleep at night. Which action should the nurse implement?  -ask the client to describe the exercise schedule that he has been following

Rationale: *to determine if he is exercising too close to bedtime 8. While suctioning a client's nasopharynx, the nurse observes that the patient's oxygen saturation remains at 94%, which is the same reading obtained before starting the procedure. What action should the nurse take in response to this finding?  -complete the intermittent suction of nasopharynx *suctioning can be continued if the client’s oxygen saturation remains above 90% or does not decrease 5% from the initial baseline 9. An older male client returns to the clinic for chronic pain management after taking morphine sulfate (MS Contin) 25 mg every 12 hours. He states he took the medication only when the pain was too severe to sleep. What action should the nurse implement?  -instruct the client to take the MS Contin every 12 hours as prescribed 10. A female, unlicensed assistive personnel (UAP) is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. What action should the nurse take first?  -instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client Rationale: *a particulate filter mask is indicated for clients with airborne precautions 11. The community health nurse is making a home visit when the client, who is sitting at the kitchen table, begins to have a seizure. What action should the nurse take first?  -assist the client to the floor 12. A client is in contact isolation due to a stage IV coccyx wound infected with methicillin resistant staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries in the client’s room. In which order should the nurse perform the interventions?  -restart the IV, perform tracheostomy care, change the coccyx dressing 13. A client who has been taking diuretics for premenstrual swelling reports muscle weakness. Which serum electrolyte value should the nurse report to the healthcare provider?

 -Potassium 3.1 mEq/L (3.1 mmol/L) 14. A client diagnosed with primary open-angle glaucoma received a prescription for miotic eye drops, pilocarpine HCl (Pilocarpine). What instructions should the nurse plan to include in the client’s teaching?  - “do not allow the dropper bottle to touch the eye.” 15.

*Sleeping side  lying with hips and knees flexed prevents unnecessary pressure on support muscles, ligaments, and lumbosacral joints and reduces low back pain

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*Obesity  a BMI greater than 30

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*Hygiene self-care deficit  evaluate the client’s participation in self-care to an optimal level of capacity is the best goal to evaluate progress in recovery

18. The unlicensed assistive personnel (UAP) describes the appearance of the bowel movement s of several clients. Which descriptions warrant additional follow-up by the nurse?  -multiple hard pellets, tarry appearance, and brown liquid 19. A client with a gastronomy tube is recovering a continuous feeding, and the nurse suspects that the client has aspirated some of the feedings. What is the action by the nurse?  -stop the tube feeding and assess the client 20. *it is the best response for the nurse to provide a response that reflects what the client stated and confirms their condition is serious. 21. The nurse is caring for a male client with diminished circulation in the lower extremities. The client washes his feet in the shower but is unable to bend safely to dry his feet. While drying the client’s feet, the nurse should emphasize the need to thoroughly dry which area of the feet?  -between the toes 22. When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first?  -position the client supine for a few minutes

23. A client who lives in an assisted living facility develops cognitive impairment following a stroke. Informed consent is needed to provide additional nursing services. Who should the nurse contact?  -a daughter-in-law designated as the client’s Durable Power of Attorney (DPOA) 24. A 24-hour urine specimen is being collected for analysis of creatinine clearance. After explaining the procedure, the client tells the nurse that the first sample is in the urinal. When discarding this specimen, what action should the nurse take?  -check the sample’s pH and specific gravity 25. A client has begun a long-term maintenance therapy with lithium, which has a narrow therapeutic index. Which adverse effect is most important for the nurse to include in the teaching plan?  -toxicity 26. A postoperative client has three different PRN analgesics prescribed for varying levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What action should the nurse take first?  -assess for side effects/adverse effects of the medication 27. Which landmarks are useful to the nurse when administering an intramuscular injection in the ventrogluteal site?  -the greater trochanter and anterior superior iliac spine 28. To assess the quality of an adult client’s pain, what approach should the nurse use?  -ask the client to describe the pain 29. The home health nurse is reviewing the personal care needs of an elderly client who lives alone. Which client assessment findings indicate the need to assign unlicensed assistive personnel (UAP) to provide routine foot care and file the client’s toenails? (Select all that apply)  -diminished visual activity  syncope (dizziness) when bending  hand tremors

30. The nurse measures the client’s blood pressure (PB) and notes that it is significantly higher than the previous reading. What should the nurse do next? (Select all that apply)  -retake the client’s blood pressure in the opposite arm, determine the client’s activity and feeling prior to the BP measurement 31. A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that he has chronic constipation and had not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important for the nurse to implement?  assess for the presence of an impaction Rationale: *it is common for cultures, such as Native Americans, to believe in using home remedies and herbs before seeking medical attention. The herbal remedies used for constipation and nausea 32. A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?  -paper mask and gown 33. The home care nurse is teaching a client how to change the dressing on a new venous stasis ulcer. The client has a history of deep vein thrombosis and is allergic to latex. When removing the adhesive bandages, the nurse observes skin redness surrounding the dressing wound. What action should the nurse implement?  -replace dressing with cotton pads and silk tape Rationale: *the skin redness surrounding the wound may be due to latex in the adhesive bandages, so the bandage should be replaced with non-latex dressing, such as cotton pads and silk tape. A culture is not indicated. A topical antibiotic ointment may be used if the wound appears infected, but is not indicated for inflammatory redness created by the latex dressing. Anklebrachial pressure index compares the ratio of blood pressure in lower legs to blood pressure in arms and is used to assess circulation prior to applying compression stockings, which should not be applied since the client has an open wound.

34. An older woman with end stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take firs?  -discuss with the client her meaning of heroic measures 35. A male client has right-sided hemoglobin following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair. To assist the client in transferring from the bed to a wheelchair, what action should the nurse take?  -place the wheelchair on the client’s left side 36. A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). What intervention is most important for the nurse to implement before leaving the client alone?  -elevate the head of the bead to a 45-degree angle 37. While interviewing a client, the nurse records the assessment in the electronic health record. which statement is most accurate regarding electronic documentation during an interview a- the client's comfort level is increased when the nurse breaks eye contact to type notes into the record b- the interview process is enhanced with electronic documentation and allow the client to speak at a normal pace c- completing the electronic record during the interview is a legal obligation of the examining nurse d- the nurse has limited ability to observe nonverbal communication while entering the assessment electronically 38. The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3L/minute, and the client’s oxygen saturation level is 92%. What intervention should the nurse implement?  -place padding around the cannula tubing *reddened areas on the cheekbones are the result of pressure from the cannula tubing. Padding the tubing of the nasal cannula helps reduce the excessive pressure

39. A client on a prescribed full liquid diet has a nursing diagnosis of “Risk for impaired skin integrity related to reduced oral intake”. What snack is best to provide this client? a. beef broth, or chicken broth b. purified lowfat milk c. apple or grapefruit juice d. ensure, a liquid supplement 40. A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instructions should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client’s care?  -measure the client’s vital signs before the client walks; report the onset of any dizziness or light headedness; offer to assist the client to void prior to walking in the hall Rationale: *assessment, including need for a gait belt, and teaching should be performed by the nurse and not delegated to the UAP. 41. The nurse is caring for a hospitalized client who was placed in restraints due to confusion. The family removes the restraints while they are with the client. When the family leaves, what action should the nurse take first?  -Reassess the client to determine the need for continuing restraints. 42. While planning care for a client experiencing pain, which outcome statement should the nurse include in the plan of care?  -report a 5-point decrease on a 1 to 10 pain scale one hour after analgesia 43. The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant granulation. The wound has a gauze dressing covering the area. What action should the nurse implement?  apply a hydrocolloidal gel (Duoderm) dressing 44. An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper and skin breakdown is obvious over his sacral area. What action should the nurse implement first?

 -complete a functional assessment of the client’s self-care abilities 45. A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures he taken to save his life. The healthcare provider knows the client has a good prognosis and refuses to write a “do not resuscitate” (DNR) prescription. What action should the nurse take?  -initiate an ethics committee review of the case 46. A male client who had emergency gallbladder surgery yesterday is getting ready for discharge. The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client’s understanding of self-care at home?  -have the client demonstrate prescribed wound care 47. A female client’s significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client’s estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?  -communicate the client’s wishes to all members of the multi-

disciplinary team...