NEW HESI RN FUNDAMENTALS

1. The nurse is discharging an adult woman who was hospitalized for 5 days for treatment of pneumonia. While the nurse is reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse to implement? Provide written instructions that are easy to follow. 2. Which assessment finding is most significant in determining the level of assistance a client needs with personal care? Disorientation to time, place, and person 3. Eight hours after the removal of an indwelling catheter, a male client reports low abdominal pain, and palpation of the bladder indicates that it is distended and dull percussion. Even after assistingthe client to a standing position, he is unable to void. What action should the nurse take? Prepare to reinsert the urinary catheter. 4. The nurse notices a male client grimacing as he moves from the bed to a chair, but when asked about his pain he denies having any pain. Which intervention should the nurse implement first? Askthe client what is making him grimace. 5. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first? Respiratory rate 6. The charge nurse observes a new graduate nurse demonstrate the administration of two differentliquid medications through a gastrostomy tube used for continuous feeding, as seen in the video. What actions should the nurse take? (SATA) Confirm that the nurse determined the amount of gastric residualAdd the liquid volumes when documenting fluid intake Instruct the nurse to administer each mediation separately 7. The nurse inserts a catheter for nasotracheal suctioning as seen in the picture. What action shouldthe nurse take nest? Apply intermittent suction 8. A client who is 2 days postoperative for thoracic surgery is complaining of incisional pain 2 hours after receiving his pain medication. He rates his pain as 5 on a pain scale of 1 to 10. After placing a call to the healthcare provider, what action should the nurse implement? Instruct the client to use guided imagery and slow rhythmic breathing. 9. Am unlicensed assistive personnel (UAP) is assigned to help a female client with her bath who has viral hepatitis A and hepatic encephalopathy. What information should the nurse reinforce with the UAP? Wear gloves while giving a bath 10. The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures? Puts on new gloves when entering a client’s room. 11. The nurse is planning care for a group of clients during the night shift on a medical unit. Which client should be assessed regularly during the night for sleep apnea? An older male with multiple problems, including obesity, diabetes, and hypertension. 12. It is most important for the nurse to recalculate the Braden scale for a client who has developed which problem? Urinary incontinence 13. A male client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger-widths betweenthe top of the crutch and the client’s axilla. What action should the nurse take? Proceed with teaching the client how to walk with the crutches. 14. After experiencing symptoms caused by an abnormal heart rhythm, a client is placed on a temporary pacemaker. When the client expresses concern and fear of the pacemaker, how shouldthe nurse respond? Encourage discussion about the concern and fears. 15. Prior to initiating digital removal of a fecal impaction, it is important for the nurse to perform which client assessment? Vital signs 16. The mother of a child with Tetrology of Fallot ask the nurse, “ Why did this happen to my baby? What did I do wrong?” Which response is most helpful? “This must be a very difficult time for you.” 17. The healthcare provider prescribes bladder irrigation to maintain patency of a client’s indwelling urinary catheter. Which intervention should the nurse implement? Use sterile syringe to irrigate the normal saline 20 ml 18. Two nurses assess a client for a pulse deficit and count an apical pulse for 72 beats/minute and a radial pulse of 88 beats/minute. What action should the nurses take? Obtain a second pulse deficit reading 19. A female who is 1 day post mastectomy is crying when the nurse enters the room. What action should the nurse take? Stay with the client in silence while touching her forearm 20. A 24-hour urine collection is in progress. The client tells the nurse that the last voiding was accidentally flushed instead of saving in the container. What intervention should the nurse initiate? Discard the urine and start another 24-hour period 21. A confused elderly male client is having trouble sleeping at night and is sometimes found wandering the hallway. What nursing intervention should the nurse implement first? Provide a back rub at bedtime 22. A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save his life. The healthcare provider knows the client has agood prognosis and refuses to write a “do not resuscitate” (DNR) prescription. What action should the nurse take? Initiate an ethics committee review of the case 23. The nurse is preparing to feed a newly admitted elderly male client who is debilitated, but is ableto respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain? Client's ability to chew and swallow 24. The nurse enters the room of a client with a Clostridium difficile infection to administer an intravenous antibiotic. The unlicensed assistive personnel (UAP) is in the room cleaning the client’sbuttocks and states the client has been incontinent with diarrhea. The UAP is wearing gloves but not a gown. What action should the nurse implement first? Tell UAP put a gown on 25. The computer documentation system shuts down while the nurse is entering the client’s physical assessment data. What should the nurse do first? Wait for notification services department of the situation 26. In assessing a client who has a nursing diagnosis ofspiritual distress, which action should thenurse take first? Assist and support the client in establishing short-term goals. 27. During transfer to the medical unit, a client who experienced an acute change in level of consciousness became increasingly confused and combative, justifying soft wrist restraints for the client’s upper and lower extremities. Which intervention is most important for the nurse to implement on admission? Determine baseline neuro status 28. (PICTURE OF EAR AND EAR DROPS) The nurse prepares to administer ear drops to an adolescent client as seen in the picture. What should the nurse do next? Pull ear auricle downward 29. The nurse measures the client’s blood pressure (BP) and notes that it is significantly higher than the previous reading. What should the nurse do next? (Select all that apply)Retake the pt's Bp in opposite arm** Determine the pt's activity and feelings prior to bp measurement 30. A male client with limited mobility is discharged with home health services. When the home health nurse arrives, the client asks what he can do for the swelling in his leg. Which actin should the nurse implement? Instruct pt to flex both of his feet several times a day 31. Which information is most important for the nurse to consider when preparing to transfer a client from the bed to a chair? The pt's ability to bear weight on lower extremities 32. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). The pulse oximeter alarm is flashing without displaying a percentage of oxygen. Which action should the nurse implement? exchange pulse ox for another monitor 33. Two days after surgery a male client experiences incisional pain while dangling his feet at the bedside and he refuses to ambulate as prescribed. The nurse establishes a problem of, “Activity intolerance related to pain.” Based in this problem, which outcome statement is best for the nurse to include in the client’s plan of care? The client will Ambulate without discomfort 34. After assessing a client, the nurse identifies three nursing problems. When developing the client’s plan of care, which action should the nurse take next? Prioritize the identified nursing diagnoses 35. After reviewing the admission assessment of a client with chronic pain, which interventions should the nurse include in this client’s plan of care? (Select all that apply) Provide comfort measures such as topical warm application and tactile massageImplement a 24h schedule of routine administration of prescribed analgesic Determine client's subjective measure of pain using a numerical pain scale 36. A client is discharged to a long-term care facility with an indwelling urinary catheter. Which nursing action should be included in the plan of care to reduce the client’s risk for infection related to the catheter? Encourage increased intake of oral fluids 37. The electronic medication system alerts the nurse that the medication dose scanned is two times higher than the dose prescribed. What action should the nurse implement? Convert the dose on hand to match the prescribed dose 38. A male client with chronic debilitating heart disease asks the nurse to help him die because he believes that he will be better off dead rather than living under the current circumstances. The nurse supports the client and considers providing the family with a does of medications that can result in the client’s death. If the nurse acts on this intention, what is the most likely consequence?The nurse will be prosecuted for the murder of the pt 39. 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? Complete the intermittent suction of nasopharynx 40. The grandmother of a young adult male admitted to the psychiatric unit yesterday requests information about her grandson’s treatment plan. Before answering the family member’s question, what action should the nurse take? Ensure that the signed release of info includes thegrandmother 41. When providing health teaching to elderly clients, what action is most important for the nurse to implement? Use everyday language when explaining issue 42. A male client presents to the clinic stating that he has a high stress job and is having difficulty falling asleep at night. The client complains of a constant headache and is seeking medication to help him sleep. Which intervention should the nurse implement? Determine the client's sleep andactivity pattern 43. To assess the quality of an adult client’s pain. What approach should the nurse use? Ask the pt to describe pain 44. The nurse is planning a weight reduction teaching program to be implemented at a community health center. Which goal is best for clients who are approximately fifteen percent over their ideal wight and wish to participate in the weight loss program? Fat intake between 20 to 30 percent of total daily intake 45. The nurse prepares to irrigate the ear of an adult client. The client is positioned with the head tilted slightly toward the affected side and the emesis basin positioned under the ear. What actionshould the nurse take next? confirm the temperature of the irrigation solution 46. The home health nurse visits a client who has a serum sodium level of 123 mEq/L. To explore possible etiologies for this value, what questions should the nurse ask the client? How much waterand ice chips do you have each day? 47. The healthcare provider prescribes hydroxyzine (Vistaril) 35 mg IM for a client who is vomiting. The available drug is labeled, 50 mg/ml. How many ml should the nurse administer? 0.7ml 48. The nurse finds a confused female client wandering in the hallway during the night. What actionshould the nurse implement? (Select all that apply) Raise the side rails of bed Escort her back to room Secure bed alarm on mattress 49. A client in the outpatient clinic complains of experiencing hard, infrequent stools. Which instruction should the nurse provide this client? Drink 6-8 large glasses of water daily 50. The nurse reviews discharge instructions for a male client with obstructive sleep apnea syndrome (OSAS). The client tells the nurse that he likes to drink a glass of wine before going to bed. How should the nurse respond? Offer to contact healthcare provider about a prescription for a sleepingaid 51. The home care nurse has identified the problem “Risk for hopelessness” for a male client who is terminally ill with a life expectancy for several days. Which instruction should the nurse provide the client’s spouse? Listen for changes in what the client hopes for and try to help meet his goals 52. The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client’s auricle upand back and prepares the thermometer. What action should the nurse implement? A Demonstrate the correct technique for pulling the ear down and back 53. A journalist asks the nurse working in the Emergency Department about condition of a local politician recently admitted to the medical center following a publicly reported building fire. What action should the nurse take? Obtain verbal consent from family member before discussing the client’s condition 54. Which outcome statement can be used in the planning stage of the nursing process? The clientwill demonstrate ability to change ostomy bag in two days 55. The nurse observes an adult woman perform a return demonstration of diaphragmatic breathing. The client inhales while holdin