HESI Practice 2 VERIFIED 100% SOLUTIONS 2023/2024

HESI Practice 2 VERIFIED 100% SOLUTIONS A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erikson, she is involved in what developmental stage? - ANSWER Generativity. A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client? - ANSWER Assist and support the client in establishing short-term goals. How should the nurse handle linens that are soiled with incontinent feces? - ANSWER Place the soiled linens in a pillow case and deposit them in the dirty linen hamper. The nurse removes the dressing on a client's heel that is covering a pressure sore oneinch in diameter and finds that there is straw-colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record? - ANSWER One-inch pressure sore draining serous fluid. Which statement correctly identifies a written learning objective for a client with peripheral vascular disease? - ANSWER Upon discharge, the client will list three ways to protect the feet from injury. A female nurse who sometimes tries to save time by putting medications in her uniform pocket to deliver to clients, confides that after arriving home she found a hydrocodone (Vicodin) tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern? - ANSWER Accused of diversion. A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from the 24-hour dietary recall? (Select all that apply.) - ANSWER Snack of potato chips, and diet soda. Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee. Breakfast of eggs, bacon, toast, and coffee. Bedtime snack of crackers and milk. Which statement is an example of a correctly written nursing diagnosis statement? - ANSWER Ineffective coping related to response to positive biopsy test results. A client is demonstrating a positive Chvostek's sign. What action should the nurse take? - ANSWER Ask the client about numbness or tingling in the hands. A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented? - ANSWER Continue gabapentin. 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. What is the rationale for using the nursing process in planning care for clients? - ANSWER As a tool to organize thinking and clinical decision making about clients' healthcare needs. Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse implement in response to this situation? - ANSWER Document the events that occurred in the nurses' notes. When caring for an immobile client, what nursing diagnosis has the highest priority? - ANSWER Impaired gas exchange. A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. What action should the nurse implement to cope with these feelings of frustration? - ANSWER Examine one's own culturally based values, beliefs, attitudes, and practices. A client who has been on bedrest for several days now has a prescription to progress activity as tolerated. When the nurse assists the client out of bed for the first time, the client becomes dizzy. What action should the nurse implement? - ANSWER Advise the client to sit on the side of the bed for a few minutes before standing again. A single mother of two teenagers, ages 16 and 18, was just told that she has advanced cancer. She is devastated by the news, and expresses her concern about who will care for her children. Which statement by the nurse is likely to be most helpful at this time? - ANSWER "Tell me what you would like to see happen with your children in the future." The nurse notes that a client consistently coughs while eating and drinking. Which nursing diagnosis is most important for the nurse to include in this client's plan of care? - ANSWER Risk for aspiration. The nurse is caring for a client who is weak from inactivity because of a 2-week hospitalization. In planning care for the client, the nurse should include which range of motion (ROM) exercises? - ANSWER Active ROM exercises to both arms and legs two or three times a day. What activity should the nurse use in the evaluation phase of the nursing process? - ANSWER Examine the effectiveness of nursing interventions toward meeting client outcomes. The charge nurse observes an unlicensed assistive personnel (UAP) bending at the waist to lift a 20-pound box of medical supplies off the treatment room floor. What instruction should the charge nurse provide to the UAP? - ANSWER Bend at the knees when lifting heavy objects. The home health nurse visits an elderly female client who had a stroke three months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care? - ANSWER The nurse notes that there are numerous scatter rugs throughout the house. A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, "Will it hurt to have my tonsils and adenoids taken out?" Which response is best for the nurse to provide? - ANSWER "It may hurt but we'll give you medicine to help you feel better." An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first? - ANSWER Drape the sheets over the footboard of the bed. As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy in the treatment room, he cries continuously. What intervention should the nurse implement? - ANSWER Ask the mother to be present to soothe the child. While the nurse is administering a bolus feeding to a client via nasogastric tube, the client begins to vomit. What action should the nurse implement first? - ANSWER Discontinue the administration of the bolus feeding.