HESI RN FUNDAMENTALS Studienführer, Klassennotizen & Zusammenfassungen

Post surgery, monitor for thrombophlebitis especially in clients who were in the ______ position during surgery - Answer lithotomy Post surgery, maintain NPO status until - Answer gag reflex and peristalsis has returned If the client does not have a urinary catheter, the client is expected to void within ____________ - Answer 6-8 H postoperatively depending on the type of anesthesia delivered; ensure that the amount is at least 200 mL Assessment of postoperative pneumonia - Answer...

A client with acute hemorrhagic anemia is to receive four units of packed red blood cells (RBCs) as rapidly as possible. Which intervention is most important for the nurse to implement? - Answer Ensure the accuracy of the blood type match An older client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? - Answer Gently lift the client when moving into a desired position A client with chronic kidney disease (CKD) selects ...

During the initial physical assessment of a newly admitted client with a pressure ulcer, a LPN observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate? -Answer The nurse provided supportive nursing care for the well-being of the client. A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight and that the client is now lyin...

During a routine assessment, an obese 50-year-old client states, "I feel so unlovable because of my weight." Which is the best response by the nurse? A. Reassure the client that many obese people have concerns about sex. B. Remind the client that sexual relationships need not be affected by obesity. C. Determine the frequency of sexual intercourse. D. Ask the client to talk about specific concerns. - Answer Option D provides an opportunity for the client to verbalize concerns an...

Which area of the hands requires special attention before you begin a surgical hand scrub? A) The area under each fingernail B) The back of the hands C) The area between each finger D) The palm of each hand - Answer B When opening a sterile pack, which of the following actions would compromise the sterility of the instruments and supplies inside the pack? A) Opening the sterile pack just prior to the procedure B) Allowing movement of team members around the field C) Keeping steri...

While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement? - Answer Instruct the client to take slow deep breaths and stop bearing down. The nurse assesses an immobile, elderly male client and determines that his blood pressure is 138/60, his temperature is 95.8 F, and his output is 100 ml of concentrated urine during the last hour. He has wet-sounding lung sounds...

The nurse encounters resistance when inserting the tubing into a client's rectum for a tap water enema. What action should the nurse implement? - Answer Ask the client to relax and run a small amount of fluid into the rectum. The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include in the dietary plan? - Answer Vitamin B12. An older client who is able to stand but not to ambulate re...

What position should keep a dysphagia pt during eating? - Answer High Fowler's during eating keep elevated at least 1h after eating A UAP is going to fee a dysphagia pt ice tea. - Answer Need to add thickening agent to all liquids. No need to be at room temperature. Blanching occurs when the fingernail bed is compressed. - Answer Normal pt's functional ability related to nutrition? - Answer pt's ability to feed herself with hand . functional. How much calories does a ad...

The nurse is assessing a client with dark skin who is in Respiratory Distress. Which client response should the nurse evaluate to determine cyanosis in this particular client? A. Cyanosis in a client with dark skin is seen in the sclera B. Abnormal skin color changes in a client with dark skin cannot be determined C. The lips and mucus membranes of a client with dark skin are dusky in color D. Blanching the soles of the feet in a client with dark skin reveals cyanosis - Answer C. The li...

In assisting an older adult client prepare to take a tub bath, which nursing action is most important? - Answer Check the bath water temperature. By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection? - Answer Mode of transmission The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction? - Answer Perform range...