Fundamentals Hesi Review
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A post-operative client has three different PRN analgesics
prescribed for different levels of pain. The nurse inadvertently
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administers a dose that is not within the prescribed
parameters. What action should the nurse take first?
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A: Determine if the pain was relieved.
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B: Complete a medication error report.
C: Assess for side effects of the medication.
D: Document the client's responses. Ans: C: Assess for side
effects of the medication.
The UAP describes the appearance of the bowel movements of
several clients. Which descriptions warrant additional follow-
up by the nurse?(SATA)
A: Multiple hard pellets
B: Brown liquid
C: Formed but soft
D: Solid with red streaks
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E: Tarry appearance Ans: A, B, D, E
An elderly woman comes to the clinic because of vaginal
bleeding. The healthcare provider finds a vaginal tear, which
the client reports is likely to have occurred during unprotected
sexual intercourse. Which content is most important for the
nurse to include in the client's teaching plan?
A: The importance of using vaginal lubricants.
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B: Methods used to practice safe sex.
C: Information about alternative ways to express sexuality.
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D:Intercourse positions that help prevent tears. Ans: A: The
importance of using vaginal lubricants.
While suctioning a client's nasopharynx, the nurse observes
that the client's oxygen saturation remains at 94%, which is the
same reading obtained prior to starting the procedure. What
action would the nurse take in response to this finding?
A: Reposition the pulse oximeter clip to obtain a new reading.
B: Stop suctioning until the pulse oximeter reading is above
95%.
C: Complete the intermittent suction of the nasopharynx.
D: Apply an oxygen mask over the client's nose and mouth.
Ans: C: Complete the intermittent suction of the nasopharynx.
An older woman with end-stage heart disease is hospitalized
for severe heart failure. She is alert, oriented, and requests
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that no heroic measures are implemented if her breathing
stops. What actions should the nurse take first?
A: Discuss with the client her meaning of heroic measures.
B: Obtain a DNR.
C: Set up a family conference to discuss the client.
D: Consult the palliative care team about the client's care.
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Ans: A: Discuss with the client her meaning of heroic
measures.
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A client diagnosed with primary open-angle glaucoma received
a prescription for biotic eye drops, pilocarpine HCl. What
instruction should the nurse plan to include in this client's
teaching?
A: "Do not allow the dropper bottle to touch the eye."
B: "Administer the medication directly on the cornea."
C: :Squeeze the eye closed after administering the drops."
D: Wash your hands after administration of eye drops." Ans:
A: "Do not allow the dropper bottle to touch the eye."
The home health nurse is reviewing the personal care of an
elderly client who lives alone. Which client assessment
findings indicate the need to assign the UAP to provide routine
foot care and file the client's toenails?(SATA)
A: Syncope when bending.