HESI RN FUNDAMENTALS TESTBANK Exam Questions and Answers latest update 2023/2024 100% A+ graded

To assess the quality of an adult client’s pain, what approach should the nurse use? C A) Observe body language and movement. B) Provide a numeric pain scale. C) Ask the client to describe the pain. D) Identify effective pain relief measures. A client who has been diagnosed with terminal cancer tells the nurse, “The doctor told me I have cancer and do not have long to live.” Which response is best for the nurse to provide? A) “That’s correct, you do not have long to live” D B) “Would you like me to call your minister?” C) “Don't give up, you still have chemotherapy to try.” D) “Yes, your condition is serious.” When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first? C 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 the client to stand at bedside. Female unlicensed assistive personnel (UAP) are assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP request a change in assignment, stating she has not yet been fitted for a particulate filter mask. What action should the nurse take? D 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. A policy requiring the removal of acrylic nails by all nursing personnel was implemented six months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved? A) Number of the staff-induced skin injuries. B) Client satisfaction survey. C) Rate of needlestick injuries by nurses. D) Healthcare-associated infection rates. 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 assisting with client’s care? (Select all that apply.) A) Instruct the client about signs of orthostatic hypertension B) Determine if the client needs to have a gait belt applied C) Measure the clients vital signs before the client walks. D) Offer to assist the client to void prior to walking in the hall. E) Report the onset of any dizziness or light headedness. A client has begun a long-term maintenance therapy with lithium, which has a narrow therapeutic index. Which adverse effect is most important for nurse to include in the teaching plan? A) Dependence. B) Toxicity. C) Interaction. D) Tolerance. 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 interview process is enhanced with electronic documentation and allows the client to speak at a normal pace. B) Completing the electronic record during an interview is a legal obligation of the examining nurse. C) The nurse has limited ability to observe nonverbal communication while entering the assessment electronically. D) The client’s comfort level is increased when the nurse breaks eye contact to type notes into the record. 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 nurse contact? A) The client’s oldest living child, a lawyer, who is visiting from out of town. B) A daughter -in-law designated as the client’s Durable Power of Attorney (DPOA). C) The client’s youngest son, identified by family members as the family spokesperson. D) The client’s spouse who lives in the independent living unit of the facility. A client is in contact isolation due to stage IV coccyx wound infected with methicillin resistant staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client’s room. In which order should the nurse perform the interventions? A) Change coccyx dressing, perform tracheostomy care, restart the IV. B) Perform tracheostomy care, change coccyx dressing, restart the IV. C) Restart the IV, perform tracheotomy care, change coccyx dressing. D) Change coccyx dressing, restart the IV, perform tracheostomy care. What self-care outcome is best for the nurse to use in evaluating a client’s recovery form a stroke that resulted in left- sided hemiparesis? A) Promote independence by allowing client to perform all self-care activities. B) Participates in self-care to optimal level of capacity. C) Client verbalizes importance of hygienic practices in the recovery process. D) Self-care needs to be completed by the unlicensed assistive personnel.