HESI RN Fundamentals Updated Solution A+

HESI RN Fundamentals Updated Solution A+ A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I have been told that it is harmful to bathe during my period." Which action should the nurse take first? A. Accept and document the client's wish to refrain from bathing. B. Offer to give the client a bed bath, avoiding the perineal area. C. Obtain written brochures about menstruation to give to the client. D.Teach the importance of personal hygiene during menstruation with the client. - ANS-Teach the importance of personal hygiene during menstruation with the client. A 65-year-old client who attends an adult daycare program and is wheelchairmobile has redness in the sacral area. Which instruction is most important for the nurse to provide? A. Take a vitamin supplement tablet once a day. B. Change positions in the chair at least every hour. C. Increase daily intake of water or other oral fluids. D.Purchase a newer model wheelchair - ANS-Change positions in the chair at least every hour. After a needle stick occurs while removing the cap from a sterile needle, which action should the nurse implement? A. Complete an incident report. B. Select another sterile needle. C.Disinfect the needle with an alcohol swab. D. Notify the supervisor of the department immediately. - ANS-Select another sterile needle. After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond? A. Provide the client with a list of Internet sites that answer frequently asked questions about medications. B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library. C.Reassure the client that information about the medication is included in the written instructions. D. Encourage the client to call the clinic nurse or health care provider if any questions arise. - ANS-Encourage the client to call the clinic nurse or health care provider if any questions arise. After the nurse tells an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all health care providers and nurses. How should the nurse respond? A. Ask the client to remain quiet so the procedure can be performed safely. B. Concentrate on completing the insertion as efficiently as possible. C. Calmly reassure the client that the discomfort will be temporary. D. Tell the client a joke as a means of distraction from the procedure. - ANSCalmly reassure the client that the discomfort will be temporary. Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client? A. Maintain standard precautions. B. Initiate contact isolation measures. C.Insert an indwelling urinary catheter D. Instruct client in the use of adult diapers. - ANS-Maintain standard precautions. By rolling contaminated gloves inside-out, the nurse is affecting which step in the chainof infection? A.Mode of transmission B.Portal of entry C.Reservoir D.Portal of exit - ANS-Mode of transmission A client becomes angry while waiting for a supervised break to smoke a cigarette outsideand states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which intervention is best for the nurse to implement? A. Encourage the client to use a nicotine patch. B. Reassure the client that it is almost time for another break. C. Have the client leave the unit with another staff member. D. Review the schedule of outdoor breaks with the client. - ANS-Review the schedule of outdoor breaks with the client. A client has a nasogastric tube connected to low intermittent suction. When administering medications through the nasogastric tube, which action should the nurse dofirst? A. Clamp the nasogastric tube. B. Confirm placement of the tube. C. Use a syringe to instill the medications. D. Turn off the intermittent suction device. - ANS-Turn off the intermittent suction device. A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide? A. Decrease intake of fluids after the evening meal. CONTINUES...