HESI FUNDAMENTALS RN STUDY GUIDE TEST BANK Q/A(S) Updat

1. Wheezing is often associated with asthma- assess breathing patterns and learn about any precipitating factors that caused the onset of the wheezing 2. A male client with limited mobility is discharged with home health services. When the home health nurse arrives, the client asks what he does for the swelling in his leg. Which should the nurse implement? -instruct the client to flex both of his feet several times a day 3. A client at an outpatient clinic submits a clean-catch midstream urine specimen for a routine urinalysis. In later review of the client’s medical record, which data indicates to the nurse that the specimen collection should be repeated? -the urine specimen shows multiple organisms in low colony counts Rationale: *often indicates that a contaminated specimen was obtained 4. During the admission assessment of a terminally ill male client, the client states that he is an agnostic. What is the best nursing action in response to this statement? -document the statement in the client’s spiritual assessment 5. The nurse observes a newly admitted older adult female take short stems and walk very slowly while pushing a walker in front of her. What action should the nurse take in response to these observations? -complete a full fall risk assessment of the client 6. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital signs should the nurse obtain first? -respiratory rate Rationale: *cyanosis is a bluish discoloration, an indication of hypoxemia 7. A middle-aged male client tells the nurse that two weeks ago he began exercising four times a week to lose weight and to help him sleep better. He states that it still takes him an hour to fall asleep at night. Which action should the nurse implement? -ask the client to describe the exercise schedule that he has been following Rationale: *to determine if he is exercising too close to bedtime 8. While suctioning a client's nasopharynx, the nurse observes that the patient'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? -complete the intermittent suction of nasopharynx *suctioning can be continued if the client’s oxygen saturation remains above 90% or does not decrease 5% from the initial baseline 9. An older male client returns to the clinic for chronic pain management after taking morphine sulfate (MS Contin) 25 mg every 12 hours. He states he took the medication only when the pain was too severe to sleep. What action should the nurse implement? -instruct the client to take the MS Contin every 12 hours as prescribed 10. A female unlicensed assistive personnel (UAP) is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. What action should the nurse take first? -instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client Rationale: *a particulate filter mask is indicated for clients with airborne precautions