NUR 160 HESI
A young woman who is the primary caregiver for her mother who has alzheimer's disease states
"Sometimes I hate my mother for living this long and my Dad for dying and not caring for her." How do
you respond. - ✔✔"What do you do to cope with these feelings" (invites the client to share feelings and
perceptions is most therapeutic)
advancing oral intake from NPO - ✔✔ice chips or water first then advance to a clear liquid and up.
applying a condom catheter to an older male - ✔✔shave the perineal area before beginning
apply skin prep to the penile shaft and allow to dry
wrap the adhesive strip in a spiral around the penis
leave 1 to 2 inches between the tip of the penis and condom catheter.
best strategy to implement for the client's incontinence - ✔✔establish a 2-hour voiding schedule.
checking for cyanosis in a patient who has a darker skin tone - ✔✔check the lips and mucous
membranes to see if they are dusky in color
checking gastric residual volume, 150 ml of gastric contents is aspirated what should you do next -
✔✔return all aspirated contents to the stomach followed with water and consult the agency policy
client chokes during a meal, after determining that the client can not speak what should you do -
✔✔place a fist halfway between the xiphoid process and umbilicus (then the abdominal thrust should
be administered until the FBAO is relieved. if becomes unresponsive then administer CPR)
client has influenza and vomiting for 3 days, has poor skin turgor and dry oral mucous membranes what
other S/S would you report to the nurse - ✔✔hypotension and tachycardia
during insertion of NG tube into right nares, the client starts to cough, which action should be taken next
- ✔✔withdraw the NGT to the oral pharynx, reposition the clients head and reinsert.
A young woman who is the primary caregiver for her mother who has alzheimer's disease states
"Sometimes I hate my mother for living this long and my Dad for dying and not caring for her." How do
you respond. - ✔✔"What do you do to cope with these feelings" (invites the client to share feelings and
perceptions is most therapeutic)
advancing oral intake from NPO - ✔✔ice chips or water first then advance to a clear liquid and up.
applying a condom catheter to an older male - ✔✔shave the perineal area before beginning
apply skin prep to the penile shaft and allow to dry
wrap the adhesive strip in a spiral around the penis
leave 1 to 2 inches between the tip of the penis and condom catheter.
best strategy to implement for the client's incontinence - ✔✔establish a 2-hour voiding schedule.
checking for cyanosis in a patient who has a darker skin tone - ✔✔check the lips and mucous
membranes to see if they are dusky in color
checking gastric residual volume, 150 ml of gastric contents is aspirated what should you do next -
✔✔return all aspirated contents to the stomach followed with water and consult the agency policy
client chokes during a meal, after determining that the client can not speak what should you do -
✔✔place a fist halfway between the xiphoid process and umbilicus (then the abdominal thrust should
be administered until the FBAO is relieved. if becomes unresponsive then administer CPR)
client has influenza and vomiting for 3 days, has poor skin turgor and dry oral mucous membranes what
other S/S would you report to the nurse - ✔✔hypotension and tachycardia
during insertion of NG tube into right nares, the client starts to cough, which action should be taken next
- ✔✔withdraw the NGT to the oral pharynx, reposition the clients head and reinsert.
