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HESIHESI Test Bank-Fundamentals
Test Bank-Fundamentals Answer key
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1. The home health nurse visits an el- The nurse notes that there are numerous scatter
derly female client who had a brain rugs throughout the house. Scatter rugs pose a
attack three months ago and is now safety hazard because the client can trip on them
able to ambulate with the assistance when ambulating, so this finding has the greatest
of the quad cane. Which assessment significance in planning this client's care
finding has the greatest implications
for this clients care?
2. The nurse is digitally removing a fe- Pulse rate decreases from 78 to 52 beats/min.
cal impaction for a client. The nurse
should stop the procedure and take Parasympathetic reactions can occur as a result
corrective action if which client reac- of digital stimulation of the anal sphincter, which
tion is noted? should be stopped if the client experiences a vagal
response, such as bradycardia
3. The nurse is providing passive range Cradle the client's heel.
of motion exercises to the hip and
knee for a client who is unconscious. Passive ROM exercise for the hip and knee is pro-
After supporting the client's knee vided by supporting the joints of the knee and ankle
with one hand, what action should and gently moving the limb in a slow, smooth, firm
the nurse take next? but gentle manner, followed by bending the knee
and moving it toward the chest as far as it will go.
Bed should be raised to a comfortable working level
first
4. A client who has moderate, per- Continue gabapentin
sistent, chronic neuropathic pain
due to diabetic neuropathy takes *step 1 drugs are nonopioid analgesics
gabapentin (neurontin) and ibupro- *step 2 and 3 are narcotics and should be given
fen daily. If step 2 of the WHO pain around the clock rather than by the clients PRN re-
relief ladder is prescribed, which drug quests
protocol should be implemented?
1/8
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5. The nurse is preparing to irrigate Draw up the irrigating solution into the syringe.
a client's indwelling urinary catheter
using an open technique. What action To irrigate an indwelling urinary catheter, the nurse
should the nurse take after applying should first apply gloves, then draw up the irrigat-
gloves? ing solution into the syringe. The syringe is then
attached to the catheter and the fluid instilled, using
aseptic technique. Once the irrigating solution is in-
stilled, the client's catheter should be secured to the
drainage tubing. The urinary drainage bag can be
emptied whenever intake and output measurement
is indicated, and the instilled irrigating fluid can be
subtracted from the output at that time.
6. Which client care requires the nurse Emptying the urinary catheter drainage bag for a
to wear barrier gloves as required client with Alzheimer's disease
by the protocol for standard precau-
tions? *possible contact with body secretions, excretions,
or broken skin is an indication for wearing barrier
gloves. Emptying a urine drainage bag requires the
use of gloves.
7. What action should the nurse imple- Position prone with a small pillow below the di-
ment to prevent the formation of a aphragm
sacral ulcer for a client who is immo-
bile? *this maintains alignment and provides the best
pressure relief over the sacral bony prominence
8. What intervention should the nurse Check capillary refill of toes on lower extremity with
include in the plan of care for a Unna's paste boot
client who is being treated with an
Unna's paste boot for leg ulcers due *it becomes rigid after it dries so it is important to
to chronic venous insufficiency? check distally for adequate circulation
2/8
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Test Bank-Fundamentals Answer key
Study online at https://quizlet.com/_7j1b94
1. The home health nurse visits an el- The nurse notes that there are numerous scatter
derly female client who had a brain rugs throughout the house. Scatter rugs pose a
attack three months ago and is now safety hazard because the client can trip on them
able to ambulate with the assistance when ambulating, so this finding has the greatest
of the quad cane. Which assessment significance in planning this client's care
finding has the greatest implications
for this clients care?
2. The nurse is digitally removing a fe- Pulse rate decreases from 78 to 52 beats/min.
cal impaction for a client. The nurse
should stop the procedure and take Parasympathetic reactions can occur as a result
corrective action if which client reac- of digital stimulation of the anal sphincter, which
tion is noted? should be stopped if the client experiences a vagal
response, such as bradycardia
3. The nurse is providing passive range Cradle the client's heel.
of motion exercises to the hip and
knee for a client who is unconscious. Passive ROM exercise for the hip and knee is pro-
After supporting the client's knee vided by supporting the joints of the knee and ankle
with one hand, what action should and gently moving the limb in a slow, smooth, firm
the nurse take next? but gentle manner, followed by bending the knee
and moving it toward the chest as far as it will go.
Bed should be raised to a comfortable working level
first
4. A client who has moderate, per- Continue gabapentin
sistent, chronic neuropathic pain
due to diabetic neuropathy takes *step 1 drugs are nonopioid analgesics
gabapentin (neurontin) and ibupro- *step 2 and 3 are narcotics and should be given
fen daily. If step 2 of the WHO pain around the clock rather than by the clients PRN re-
relief ladder is prescribed, which drug quests
protocol should be implemented?
1/8
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Test Bank-Fundamentals Answer key
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5. The nurse is preparing to irrigate Draw up the irrigating solution into the syringe.
a client's indwelling urinary catheter
using an open technique. What action To irrigate an indwelling urinary catheter, the nurse
should the nurse take after applying should first apply gloves, then draw up the irrigat-
gloves? ing solution into the syringe. The syringe is then
attached to the catheter and the fluid instilled, using
aseptic technique. Once the irrigating solution is in-
stilled, the client's catheter should be secured to the
drainage tubing. The urinary drainage bag can be
emptied whenever intake and output measurement
is indicated, and the instilled irrigating fluid can be
subtracted from the output at that time.
6. Which client care requires the nurse Emptying the urinary catheter drainage bag for a
to wear barrier gloves as required client with Alzheimer's disease
by the protocol for standard precau-
tions? *possible contact with body secretions, excretions,
or broken skin is an indication for wearing barrier
gloves. Emptying a urine drainage bag requires the
use of gloves.
7. What action should the nurse imple- Position prone with a small pillow below the di-
ment to prevent the formation of a aphragm
sacral ulcer for a client who is immo-
bile? *this maintains alignment and provides the best
pressure relief over the sacral bony prominence
8. What intervention should the nurse Check capillary refill of toes on lower extremity with
include in the plan of care for a Unna's paste boot
client who is being treated with an
Unna's paste boot for leg ulcers due *it becomes rigid after it dries so it is important to
to chronic venous insufficiency? check distally for adequate circulation
2/8
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