1. Wheezing is often associated with asthma- assess breathing patterns and learn
about any precipitating factors that caused the onset of the wheezing
2. A male client with limited mobility is discharged with home health services.
When the home health nurse arrives, the client asks what he does for the
swelling in his leg. 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 specimen
for routine urinalysis. In later review of the client’s medical record, which data
indicates 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
m
er as
4. During the admission assessment of a terminally ill male client, the client states
co
eH w
that he is an agnostic. What is the best nursing action in response to this
o.
rs e
statement?
ou urc
-document the statement in the client’s spiritual assessment
o
5. The nurse observes a newly admitted older adult female take short stems and
aC s
vi y re
walk very slowly while pushing a walker in front of her. What action should the
nurse take in response to these observations?
ed d
ar stu
-complete a full fall risk assessment of the client
sh is
Th
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https://www.coursehero.com/file/60243139/2019-Hesi-Fundamentals-47-QAdocx/
, 6. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital
signs 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
the nurse 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 before
starting 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 not decrease 5% from the initial baseline
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
This study source was downloaded by 100000831125505 from CourseHero.com on 09-30-2021 06:24:17 GMT -05:00
https://www.coursehero.com/file/60243139/2019-Hesi-Fundamentals-47-QAdocx/
about any precipitating factors that caused the onset of the wheezing
2. A male client with limited mobility is discharged with home health services.
When the home health nurse arrives, the client asks what he does for the
swelling in his leg. 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 specimen
for routine urinalysis. In later review of the client’s medical record, which data
indicates 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
m
er as
4. During the admission assessment of a terminally ill male client, the client states
co
eH w
that he is an agnostic. What is the best nursing action in response to this
o.
rs e
statement?
ou urc
-document the statement in the client’s spiritual assessment
o
5. The nurse observes a newly admitted older adult female take short stems and
aC s
vi y re
walk very slowly while pushing a walker in front of her. What action should the
nurse take in response to these observations?
ed d
ar stu
-complete a full fall risk assessment of the client
sh is
Th
This study source was downloaded by 100000831125505 from CourseHero.com on 09-30-2021 06:24:17 GMT -05:00
https://www.coursehero.com/file/60243139/2019-Hesi-Fundamentals-47-QAdocx/
, 6. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital
signs 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
the nurse 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 before
starting 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 not decrease 5% from the initial baseline
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
This study source was downloaded by 100000831125505 from CourseHero.com on 09-30-2021 06:24:17 GMT -05:00
https://www.coursehero.com/file/60243139/2019-Hesi-Fundamentals-47-QAdocx/
