HESI RN FUNDAMENTALS

A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administer a dose that is not within the prescribed parameters. What action should the nurse take first? C • Determine if the pain was relieved. • Complete a medication error report. • Assess for side effects of the medication. • Document the client’s responses. The unlicensed assistive personnel (UAP) describe the appearance of the bowel movements of several clients. Which descriptions warrant additional follow-up by the nurse? (Select all that apply.) ABDEA) Multiple hard p• Brown liquid. • Formed but soft. • S o l i d w i t h r e d s t r e a k s . E ) T a r r y a p p e a r a n c e . An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vaginal tear, which the client reports is likely to have occurred during unprotected sexual intercourse. Which content is most important for the nurse to include in this client’s teaching plan? A • The importance of using vaginal lubricants. • Methods used to practice safe sex. • Information about alternative ways to express sexuality. • Intercourse positions that help prevent tears. A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair. To assist the client in transferring from the bed to a wheelchair, what action should the nurse take? A) Have the client put both arms around the nurse’s neck for support) Place thewheelchair on the client’s left side. • Instruct the client to look at his feet. • Instruct the client total slow, deep breaths while transferring. The nurse observes a newly admitted older adult female take short steps and walk very slowly while pushing a walkerin front of her. What action should the nurse take in response to these observations? A • Complete a full fall risk assessment of the client. • Teach the client to take longer steps at faster pace. • Suggest that the the client use a wheelchair instead of a walker. • Place client on bedrest until the healthcare provider is notified. A client is receiving ketorolac (Toradol) IM 45 mg IM 6 hours for postoperative pain. The available 2 ml vial is labeled,Toradol IM 30 mg/ml, how many should the nurse administer? (Round to the nearest tenth.) 1.5mg While suctioning a client’s nasopharynx, the nurse observes that the client’s oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding? C • Reposition the pulse oximeter clip to obtain a new reading. • Stop suctioning until the pulse oximeter reading is above 95%.C) Complete the intermittent suction of the nasopharynx. D) Apply an oxygen mask over the client’s nose and mouth. An older woman with end stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requeststhat no heroic measures are implemented if her breathing stops. What action should the nurse take first? A • Discuss with the client her meaning of heroic measures. • Obtain a “do not resuscitate” (DNR) prescription. • Set up a family conference to discuss the clients. • Consult the palliative care team about client’s care. A client diagnosed with primary open-angle glaucoma received a prescription for biotic eye drops, pilocarpine (Pilocarpine). What instruction should the nurse plan to include in this client’s teaching? A • “Do not allow the dropper bottle to touch the eye.” • “Administer the medication directly on the cornea.” • “Squeeze your eye closed after administering the drops.” • “Wash your hands after each administration of eye drops.”