Hesi Fundamentals Questions and Answers 2022/2023

When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first? A: Apply the blood pressure cuff securely. B: Record the client's pulse rate and rhythm. C: Position the client supine for a few minutes. D: Assist client to stand at bedside. C: Position the client supine for a few minutes. 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. B: Hand tremors. C: Diminished visual acuity. D: Urinary incontinence. E: Shuffling gait. A, B, C 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 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. A: Discuss with the client her meaning of heroic measures. **When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next? A: Modify the nursing interventions to achieve the client's goals. B: Determine if the expected outcomes were realistic. C: Review related professional standards of care. D: Obtain current client data to compare with expected outcomes. D: Obtain current client data to compare with expected outcomes. A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instructions should the nurse give to the UAP who is assisting with the client's care?(SATA) A: Instruct the client about signs of orthostatic hypertension. B: Determine if the client needs to have a gait belt applied. C: Measure the client's vital signs before the client walks.