HESI FUNDAMENTALS RN EXIT V1TEST BANK Q/A(S)

HESI FUNDAMENTALS RN EXIT V1TEST BANK Q/A(S) 1. Wheezing is often associated with asthma- assess breathing patterns and learnabout any precipitating factors that caused the onset of the wheezing 2. A male client with limited mobility is discharged with home health services. Whenthe home health nurse arrives, the client asks what he does for the swelling in hisleg. 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 specimenfor a routine urinalysis. In later review of the client’s medical record, which dataindicates 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 statesthat 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 andwalk very slowly while pushing a walker in front of her. What action should thenurse 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 vitalsigns 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 thenurse 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 tostarting 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 notdecrease 5% from the initial baseline Downloaded by denis munene () lOMoARcPSD| 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 fora 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 airborneprecautions 11.The community health nurse is making a home visit when the client, who is sittingat the kitchen table, begins to have a seizure. What action should the nurse take first? -assist the client to the floor 12.A client is in contact isolation due to a stage IV coccyx wound infected with methicillin resistant staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client’s room. In which ordershould the nurse perform the interventions? -restart the IV, perform tracheostomy care, change the coccyx dressing 13.A client who has been taking diuretics for premenstrual swelling reports muscle weakness. Which serum electrolyte value should the nurse report to the healthcare provider? -Potassium 3.1 mEq/L (3.1 mmol/L) 14.A client diagnosed with primary open-angle glaucoma received a prescription formiotic eye drops, pilocarpine HCl (Pilocarpine). What instructions should the nurse plan to include in the client’s teaching? - “do not allow the dropper bottle to touch the eye” 15.*Sleeping side lying with hips and knees flexed prevents unnecessary pressure on support muscles, ligaments, and lumbosacral joints and reduces low backpain 16.*Obesity a BMI greater than 30 17.*Hygiene self-care deficit evaluate the client’s participation in self-care to optimal level of capacity isthe best goal to evaluate progress in recovery Downloaded by denis munene (denismunene