-NEW HESI RN FUNDAMENTALS

NEW HESI RN FUNDAMENTALS - REAL QUESTIONS&ANSWERS - HESI RN FUNDAMENTALS SAMPLE QUESTIONS/DESCRIPTION/PREVIEW - 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 - 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 -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 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. 1. Which assessment finding is most significant in determining the level of assistance a client needs with personal care? Disorientation to time, place, and person 2. 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. 3. 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. 4. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first? Respiratory rate 5. 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 6. The nurse inserts a catheter for nasotracheal suctioning as seen in the picture. What action shouldthe nurse take nest? Apply intermittent suction 7. 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. 8. 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 9. 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. 10. 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. 11. It is most important for the nurse to recalculate the Braden scale for a client who has developed