HESI: NUR 310 / NUR 310 (LATEST
UPDATE) | QUESTIONS AND VERIFIED ANSWERS 100%
CORRECT | GRADED A+
A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action
has the highest priority?
Ensure cultural customs are observed.
Increase oxygen flow to 4L/minute.
Auscultate bilateral lung fields.
Inform the family that death is imminent. - ANSWER-Inform the family that death is imminent.
An audible gurgling sound produced by a dying client is characteristic of ineffective clearance of
secretions from the lungs or upper airways, causing a "rattling" sound as air moves through the
accumulated fluid. The nursing priority in this situation is to convey to the family that the
client's death is imminent (D). Although culturally sensitive care should be observed throughout
the client's plan of care (A), this is not the priority at this time. Administration of oxygen may be
expected care, but a flow rate greater than 2 L/minute (B) is not palliative care. (C) may provide
additional information, but is not necessary as death approaches.
When making the bed of a client who needs a bed cradle, which action should the nurse
include?
Teach the client to call for help before getting out of bed.
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,Keep both the upper and lower side rails in a raised position.
Keep the bed in the lowest position while changing the sheets.
Drape the top sheet and covers loosely over the bed cradle. - ANSWER-Drape the top sheet and
covers loosely over the bed cradle.
A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top
sheet and covers loosely over the cradle (D). A client using a bed cradle may still be able to
ambulate independently (A) and does not require raised side rails (B). (C) causes the nurse to
use poor body mechanics.
Before administering a client's medication, the nurse assesses a change in the client's condition
and decides to withhold the medication until consulting with the healthcare provider. After
consultation with the healthcare provider, the dose of the medication is changed and the nurse
administers the newly prescribed dose an hour later than the originally scheduled time. What
action should the nurse implement in response to this situation?
Notify the charge nurse that a medication error occurred.
Submit a medication variance report to the supervisor.
Document the events that occurred in the nurses' notes.
Discard the original medication administration record. - ANSWER-Document the events that
occurred in the nurses' notes.
The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related to lack of
motivation" for a client with Type 2 diabetes. Which finding supports this nursing diagnosis?
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, Does not check capillary blood glucose as directed.
Occasionally forgets to take daily prescribed medication.
Cannot identify signs or symptoms of high and low blood glucose.
Eats anything and does not think diet makes a difference in health. - ANSWER-Eats anything and
does not think diet makes a difference in health.
Prior to administering a newly prescribed medication to a client, the nurse reviews the adverse
effects of the medication listed in a drug reference guide and determines the priority risks to the
client. While performing this action, the nurse is engaged in which step of the nursing process?
Assessment.
Analysis.
Implementation.
Evaluation. - ANSWER-Analysis.
The nurse is analyzing (B) data to establish an individualized nursing diagnosis, such as, "Risk for
injury related to side effects of drugs." This analysis is based on assessment (A) and guides the
planning and implementation (C) of care, such as the decision to monitor the client frequently.
(D) provides the nurse with information about the effectiveness of the plan of care.
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UPDATE) | QUESTIONS AND VERIFIED ANSWERS 100%
CORRECT | GRADED A+
A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action
has the highest priority?
Ensure cultural customs are observed.
Increase oxygen flow to 4L/minute.
Auscultate bilateral lung fields.
Inform the family that death is imminent. - ANSWER-Inform the family that death is imminent.
An audible gurgling sound produced by a dying client is characteristic of ineffective clearance of
secretions from the lungs or upper airways, causing a "rattling" sound as air moves through the
accumulated fluid. The nursing priority in this situation is to convey to the family that the
client's death is imminent (D). Although culturally sensitive care should be observed throughout
the client's plan of care (A), this is not the priority at this time. Administration of oxygen may be
expected care, but a flow rate greater than 2 L/minute (B) is not palliative care. (C) may provide
additional information, but is not necessary as death approaches.
When making the bed of a client who needs a bed cradle, which action should the nurse
include?
Teach the client to call for help before getting out of bed.
1|Page
,Keep both the upper and lower side rails in a raised position.
Keep the bed in the lowest position while changing the sheets.
Drape the top sheet and covers loosely over the bed cradle. - ANSWER-Drape the top sheet and
covers loosely over the bed cradle.
A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top
sheet and covers loosely over the cradle (D). A client using a bed cradle may still be able to
ambulate independently (A) and does not require raised side rails (B). (C) causes the nurse to
use poor body mechanics.
Before administering a client's medication, the nurse assesses a change in the client's condition
and decides to withhold the medication until consulting with the healthcare provider. After
consultation with the healthcare provider, the dose of the medication is changed and the nurse
administers the newly prescribed dose an hour later than the originally scheduled time. What
action should the nurse implement in response to this situation?
Notify the charge nurse that a medication error occurred.
Submit a medication variance report to the supervisor.
Document the events that occurred in the nurses' notes.
Discard the original medication administration record. - ANSWER-Document the events that
occurred in the nurses' notes.
The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related to lack of
motivation" for a client with Type 2 diabetes. Which finding supports this nursing diagnosis?
2|Page
, Does not check capillary blood glucose as directed.
Occasionally forgets to take daily prescribed medication.
Cannot identify signs or symptoms of high and low blood glucose.
Eats anything and does not think diet makes a difference in health. - ANSWER-Eats anything and
does not think diet makes a difference in health.
Prior to administering a newly prescribed medication to a client, the nurse reviews the adverse
effects of the medication listed in a drug reference guide and determines the priority risks to the
client. While performing this action, the nurse is engaged in which step of the nursing process?
Assessment.
Analysis.
Implementation.
Evaluation. - ANSWER-Analysis.
The nurse is analyzing (B) data to establish an individualized nursing diagnosis, such as, "Risk for
injury related to side effects of drugs." This analysis is based on assessment (A) and guides the
planning and implementation (C) of care, such as the decision to monitor the client frequently.
(D) provides the nurse with information about the effectiveness of the plan of care.
3|Page
