Nursing Fundamentals BSN 225 HESI Review Questions And Answers With Verified Solutions Graded A+

24 hour urine collection - The urine collected from the 1st specimen was in the bladder before the 24 hour. Specimen collection was started, so it should be discarded. Assess Feces - Multiple hard pallets may indicate problems with constipation or inadequate fluid intake. A tarry appearance or read streaks may indicate bleeding. Brown liquid may indicate diarrhea or decal impaction. Braden risk assessment- turning - A score of 10 on the Braden risk assessment scale indicate that the client should be turned frequently. This scale is a reliable tool used to measure the clients risk for the development of pressure sores. Sores range from 6-23, with the lower scores indicating the highest risk for pressure sore development. Cath insertion technique - While inserting an urinary catheter into a client & urine is observed, the catheter should be advanced another inch, to ensure that the balloon will be inflated in the bladder, rather than the urethra. Clear liquid diet - A client who is on a clear liquid diet has coffee on the tray. Black coffee is considered a clear liquid, but the nurse should remind the client that no milk or creamer can be added to the coffee. Client safety - The nurse should help the client lie back down & then explain to the spouse the need for ambulation to reduce potential postoperative complications. confused client- action - A confused client who is wandering is at risk for injury. The nurse should orient the client to her surroundings, escort the client to her room to promote sleep, & use a bed alarm to alert the nurse to further wandering behavior. Conversion- PO- g/ml- 1000mg = 1 g. 1000 mg: X mL: 200 mg : 5 mL - 200X= 1000 (5). X= 5000/200 = 25 mLCulture- constipation - It is common for cultures, such as Native Americans, to believe in using home remedies & herbs before seeking medical attention. Cascara Sagrada is one of the most commonly used herbal remedies for constipation & can cause significant cramping and nausea. Cyanosis- respiration rate - Cyanosis, a bluish discoloration, is an indication of hypoxemia, so it is most important for the nurse to assess the client's respiratory function first, followed by the remaining vital signs. Droplet precautions - The top edge of a surgical face mask should be secured over the bridge of the nose just below the eyeglasses to provide a snugly-fitting mask that prevents transmission of pathogens while the client is transported outside the room. Transporting the client without protective equipment endangers other persons who might come in contact with the client. A fitted respirator-style mask is not necessary unless the clients placed on airborne precautions for tuberculosis. Protective goggles are used by caregivers likely to be in contact with potentially contaminated body fluids & do not need to be worn by the client. Electronic Documentation - Notifying the information services department is most important to expedite the availability of the EMR & initiate problem solving in determining nursing actions to be implemented to continue client care. Family care- how - 1st the nurse should assess the wife's desires & ability to cope with this life change. The best approach at this point is to obtain information about what the wife wants & ask her how she would want to participate in her husband's care. Grimacing- assessment - Grimacing is a nonverbal sign of pain, so first this sign should be clarified, The nurse should continue to monitor for nonverbal signs of pain if the client continues to deny pain. The pain medication should be reviewed to determine what is prescribed & then administer if the client admits to pain or discomfort. HIPAA regulations - The client's condition is protected by the Privacy Rule under the Health Insurance Portivility & Accountability Act (HIPAA), & the communication/Marketing department can determine whether or not the client has authorized disclosure of his or her protected heath information to the media. Unauthorized disclosure of information is illegal.