HESI RN Fundamentals Nursing Health Assessment A Best
Practice Approach 1st edition by Jensen -Test Bank
A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She
states, "I have been told that it is harmful to bathe during my period." Which action should the nurse
take first?
A. Accept and document the client's wish to refrain from bathing.
B. Offer to give the client a bed bath, avoiding the perineal area.
C. Obtain written brochures about menstruation to give to the client.
D.Teach the importance of personal hygiene during menstruation with the client. - ✔✔ANSWER✔✔Teach
the importance of personal hygiene during menstruation with the client.
A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the
sacral area. Which instruction is most important for the nurse to provide?
A. Take a vitamin supplement tablet once a day.
B. Change positions in the chair at least every hour.
C. Increase daily intake of water or other oral fluids.
D.Purchase a newer model wheelchair - ✔✔ANSWER✔✔Change positions in the chair at least every
hour.
After a needle stick occurs while removing the cap from a sterile needle, which action should the nurse
implement?
A. Complete an incident report.
B. Select another sterile needle.
C.Disinfect the needle with an alcohol swab.
D. Notify the supervisor of the department immediately. - ✔✔ANSWER✔✔Select another sterile needle.
,After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a
client asks the nurse what to do if questions arise about the medication after getting home. How should
the nurse respond?
A. Provide the client with a list of Internet sites that answer frequently asked questions about
medications.
B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library.
C.Reassure the client that information about the medication is included in the written instructions.
D. Encourage the client to call the clinic nurse or health care provider if any questions arise. -
✔✔ANSWER✔✔Encourage the client to call the clinic nurse or health care provider if any questions
arise.
After the nurse tells an older client that an IV line needs to be inserted, the client becomes very
apprehensive, loudly verbalizing a dislike for all health care providers and nurses. How should the nurse
respond?
A. Ask the client to remain quiet so the procedure can be performed safely.
B. Concentrate on completing the insertion as efficiently as possible.
C. Calmly reassure the client that the discomfort will be temporary.
D. Tell the client a joke as a means of distraction from the procedure. - ✔✔ANSWER✔✔Calmly reassure
the client that the discomfort will be temporary.
Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse to implement
when providing care for an older incontinent client?
A. Maintain standard precautions.
B. Initiate contact isolation measures.
C.Insert an indwelling urinary catheter
D. Instruct client in the use of adult diapers. - ✔✔ANSWER✔✔Maintain standard precautions.
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chainof infection?
A.Mode of transmission
B.Portal of entry
C.Reservoir
, D.Portal of exit - ✔✔ANSWER✔✔Mode of transmission
A client becomes angry while waiting for a supervised break to smoke a cigarette outsideand states, "I
want to go outside now and smoke. It takes forever to get anything done here!" Which intervention is
best for the nurse to implement?
A. Encourage the client to use a nicotine patch.
B. Reassure the client that it is almost time for another break.
C. Have the client leave the unit with another staff member.
D. Review the schedule of outdoor breaks with the client. - ✔✔ANSWER✔✔Review the schedule of
outdoor breaks with the client.
A client has a nasogastric tube connected to low intermittent suction. When administering medications
through the nasogastric tube, which action should the nurse dofirst?
A. Clamp the nasogastric tube.
B. Confirm placement of the tube.
C. Use a syringe to instill the medications.
D. Turn off the intermittent suction device. - ✔✔ANSWER✔✔Turn off the intermittent suction device.
A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is
important for the nurse to provide?
A. Decrease intake of fluids after the evening meal.
B. Drink a glass of cranberry juice every day.
C. Drink a glass of warm decaffeinated beverage at bedtime.
D. Consult the health care provider about a sleeping pill. - ✔✔ANSWER✔✔Decrease intake of fluids after
the evening meal.
A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days.
Which intervention should the nurse implement first?
A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
B. Notify the health care provider and request a prescription for a large-volume enema.
C. Assess the client's medical record to determine the client's normal bowel pattern.
Practice Approach 1st edition by Jensen -Test Bank
A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She
states, "I have been told that it is harmful to bathe during my period." Which action should the nurse
take first?
A. Accept and document the client's wish to refrain from bathing.
B. Offer to give the client a bed bath, avoiding the perineal area.
C. Obtain written brochures about menstruation to give to the client.
D.Teach the importance of personal hygiene during menstruation with the client. - ✔✔ANSWER✔✔Teach
the importance of personal hygiene during menstruation with the client.
A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the
sacral area. Which instruction is most important for the nurse to provide?
A. Take a vitamin supplement tablet once a day.
B. Change positions in the chair at least every hour.
C. Increase daily intake of water or other oral fluids.
D.Purchase a newer model wheelchair - ✔✔ANSWER✔✔Change positions in the chair at least every
hour.
After a needle stick occurs while removing the cap from a sterile needle, which action should the nurse
implement?
A. Complete an incident report.
B. Select another sterile needle.
C.Disinfect the needle with an alcohol swab.
D. Notify the supervisor of the department immediately. - ✔✔ANSWER✔✔Select another sterile needle.
,After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a
client asks the nurse what to do if questions arise about the medication after getting home. How should
the nurse respond?
A. Provide the client with a list of Internet sites that answer frequently asked questions about
medications.
B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library.
C.Reassure the client that information about the medication is included in the written instructions.
D. Encourage the client to call the clinic nurse or health care provider if any questions arise. -
✔✔ANSWER✔✔Encourage the client to call the clinic nurse or health care provider if any questions
arise.
After the nurse tells an older client that an IV line needs to be inserted, the client becomes very
apprehensive, loudly verbalizing a dislike for all health care providers and nurses. How should the nurse
respond?
A. Ask the client to remain quiet so the procedure can be performed safely.
B. Concentrate on completing the insertion as efficiently as possible.
C. Calmly reassure the client that the discomfort will be temporary.
D. Tell the client a joke as a means of distraction from the procedure. - ✔✔ANSWER✔✔Calmly reassure
the client that the discomfort will be temporary.
Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse to implement
when providing care for an older incontinent client?
A. Maintain standard precautions.
B. Initiate contact isolation measures.
C.Insert an indwelling urinary catheter
D. Instruct client in the use of adult diapers. - ✔✔ANSWER✔✔Maintain standard precautions.
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chainof infection?
A.Mode of transmission
B.Portal of entry
C.Reservoir
, D.Portal of exit - ✔✔ANSWER✔✔Mode of transmission
A client becomes angry while waiting for a supervised break to smoke a cigarette outsideand states, "I
want to go outside now and smoke. It takes forever to get anything done here!" Which intervention is
best for the nurse to implement?
A. Encourage the client to use a nicotine patch.
B. Reassure the client that it is almost time for another break.
C. Have the client leave the unit with another staff member.
D. Review the schedule of outdoor breaks with the client. - ✔✔ANSWER✔✔Review the schedule of
outdoor breaks with the client.
A client has a nasogastric tube connected to low intermittent suction. When administering medications
through the nasogastric tube, which action should the nurse dofirst?
A. Clamp the nasogastric tube.
B. Confirm placement of the tube.
C. Use a syringe to instill the medications.
D. Turn off the intermittent suction device. - ✔✔ANSWER✔✔Turn off the intermittent suction device.
A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is
important for the nurse to provide?
A. Decrease intake of fluids after the evening meal.
B. Drink a glass of cranberry juice every day.
C. Drink a glass of warm decaffeinated beverage at bedtime.
D. Consult the health care provider about a sleeping pill. - ✔✔ANSWER✔✔Decrease intake of fluids after
the evening meal.
A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days.
Which intervention should the nurse implement first?
A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
B. Notify the health care provider and request a prescription for a large-volume enema.
C. Assess the client's medical record to determine the client's normal bowel pattern.
