HESI TEST BANK_Graded A | HEST TEST BANK_UPDATED

HESI OJO ULTIMO – Miami Dade College 155 -When assessing a client,the nurse should establish which findings as objective? (Select all that apply.) A Hypertension. B Nausea. C Diaphoresis. D Anxiety. E Edema. F Urticaria. Ans:A,C,,E,F 154-This item can have multiple correct answers. Refer to question instructions for answering information. A Review the staff nurse job description to ensure that it is clear, accurate, and current. B Assign eachstaff nurse a turn as the unit charge nurse on a regular, rotating basis. C Analyze the amount of overtime needed by the nursing staff to complete assignments. D Confirm that all of the staff nurses are being assigned to equal numbers of clients. Ans:A 153 -A client s right to give informed consent is based on which ethical principle? Multiple-Choice Single-Answer A Nonmaleficence. B Practice of beneficence C Respect for autonomy. D Commitment to fidelity. Ans:C 152 -The nurse observes an un licensed assistive personnel (UAP) using an alcohol-based cleanser after delivering a client's breakfast tray to the room. The UAP rubs both hands thoroughly for 2 minutes while standing at the door to the client's room. What action should the nurse take? A Inform the UAP that hand washing helps to promote better asepsis. B Explain that the hand rub can be completed in less than 2 minutes. C Encourage the UAP to remain in the client's room until completed. D Determine why the UAP was not wearing gloves in the client's room. Ans: A 151 -Which interventions most important to include in the nursing care plan of a client receiving furosemide (Lasix)? A Frequently assess the client's blood pressure. B Assess urinary output every shift. C Assess the client for abnormal bleeding. D Do not administer medication if the client is hypokalemic. Ans: D 150 -The nurse notices that the catheter of a client who had a transurethral resection of the prostate (TURP) 2 days ago is not draining and his bladder is distended. What action should the nurse take initially? A Milk the catheter tubing. B Discontinue the catheter. C Irrigate the catheter. D Change the catheter. Ans: C 149 -Following a devastating hurricane, a client is admitted for dehydration as the result of vomiting and diarrhea that occurred after ingesting contaminated water. The client expresses feelings of fear and anger about the destruction of homes, the loss of property due to the storm, and the looting that occurred following the storm. According to Maslow's hierarchy of needs,what priority need should be addressed first? A Physiological needs. B Safety and security. C Self-actualizat on. D Love and belonging. Ans:A 148 -A male client with diabetes mellitus Type 2, who is taking pioglitazone (Actos) PO day reports to the nurse the recent onset of nausea, accompanied by dark-colored urine, and a yellow sh cast to his skin. What instruction should the nurse provide? "A urine specimen will be needed to determine what kind of infection you have developed." B "Use insulin per sliding scale until the nausea resolves,and then resume your oral medication." C "You have become dehydrated from the nausea. You will need to rest and increase fluid intake." D "You need to seek immediate medical assistance to evaluate the cause of these symptoms." Ans :D 14 7