NEW HESI RN FUNDAMENTALS - REAL QUESTIONS&ANSWERS - HESI RN FUNDAMENTALS

The nurse is discharging an adult woman who was hospitalized for 5 days for treatment of pneumonia. While the nurse is reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse to implement? Provide written instructions that are easy to follow. 2. Which assessment finding is most significant in determining the level of assistance a client needs with personal care? Disorientation to time, place, and person 3. Eight hours after the removal of an indwelling catheter, a male client reports low abdominal pain, and palpation of the bladder indicates that it is distended and dull percussion. Even after assistingthe client to a standing position, he is unable to void. What action should the nurse take? Prepare to reinsert the urinary catheter. 4. The nurse notices a male client grimacing as he moves from the bed to a chair, but when asked about his pain he denies having any pain. Which intervention should the nurse implement first? Askthe client what is making him grimace. 5. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first? Respiratory rate 6. The charge nurse observes a new graduate nurse demonstrate the administration of two differentliquid medications through a gastrostomy tube used for continuous feeding, as seen in the video. What actions should the nurse take? (SATA) Confirm that the nurse determined the amount of gastric residualAdd the liquid volumes when documenting fluid intake Instruct the nurse to administer each mediation separately 7. The nurse inserts a catheter for nasotracheal suctioning as seen in the picture. What action shouldthe nurse take nest? Apply intermittent suction 8. A client who is 2 days postoperative for thoracic surgery is complaining of incisional pain 2 hours after receiving his pain medication. He rates his pain as 5 on a pain scale of 1 to 10. After placing a call to the healthcare provider, what action should the nurse implement? Instruct the client to use guided imagery and slow rhythmic breathing. 9. Am unlicensed assistive personnel (UAP) is assigned to help a female client with her bath who has viral hepatitis A and hepatic encephalopathy. What information should the nurse reinforce with the UAP? Wear gloves while giving a bath 10. The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures? Puts on new gloves when entering a client’s room. 11. The nurse is planning care for a group of clients during the night shift on a medical unit. Which client should be assessed regularly during the night for sleep apnea? An older male with multiple problems, including obesity, diabetes, and hypertension. 12. It is most important for the nurse to recalculate the Braden scale for a client who has developed which problem? Urinary incontinence 13. A male client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger-widths betweenthe top of the crutch and the client’s axilla. What action should the nurse take? Proceed with teaching the client how to walk with the crutches. 14. After experiencing symptoms caused by an abnormal heart rhythm, a client is placed on a temporary pacemaker. When the client expresses concern and fear of the pacemaker, how shouldthe nurse respond? Encourage discussion about the concern and fears. 15. Prior to initiating digital removal of a fecal impaction, it isimportant for the nurse to perform which client assessment? Vital signs 16. The mother of a child with Tetrology of Fallot ask the nurse, “ Why did this happen to my baby? What did I do wrong?” Which response is most helpful? “This must be a very difficult time for you.” 17. The healthcare provider prescribes bladder irrigation to maintain patency of a client’s indwelling urinary catheter. Which intervention should the nurse implement? Use sterile syringe to irrigate the normal saline 20 ml 18. Two nurses assess a client for a pulse deficit and count an apical pulse for 72 beats/minute and a radial pulse of 88 beats/minute. What action should the nurses take? Obtain a second pulse deficit reading 19. A female who is 1 day post mastectomy is crying when the nurse enters the room. What action should the nurse take? Stay with the client in silence while touching her forearm 20. A 24-hour urine collection is in progress. The client tells the nurse that the last voiding was accidentally flushed instead of saving in the container. What intervention should the nurse initiate? Discard the urine and start another 24-hour period 21. A confused elderly male client is having trouble sleeping at night and is sometimes found wandering the hallway. What nursing intervention should the nurse implement first? Provide a back rub at bedtime 22. A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save hislife. The healthcare provider knowsthe client has agood 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 23. The nurse is preparing to feed a newly admitted elderly male client who is debilitated, but is ableto respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain? Client's ability to chew and swallow 24. The nurse enters the room of a client with a Clostridium difficile infection to administer an intravenous antibiotic. The unlicensed assistive personnel (UAP) is in the room cleaning the client’sbuttocks and states the client has been incontinent with diarrhea. The UAP is wearing gloves but not a gown. What action should the nurse implement first? Tell UAP put a gown on 25. The computer documentation system shuts down while the nurse is entering the client’s physical assessment data. What should the nurse do first? Wait for notification services department of the situation