HESI Fundamentals Practice Exam #1 questions and answers latest top score.

HESI Fundamentals Practice Exam #1 questions and answers latest top score. A 35y/o client with cancer refuses to allow a nurse to insert an IV for scheduled chemo & states that she's ready to go home to die. What intervention should the nurse initiate? - correct answers.Evaluate the client's mental status for competence to refuse treatment Rationale: Competent clients have the right to refuse treatment. The nurse cannot document until the HCP is notified of the patient's wishes & a d/c RX is obtained. Advance directives & DNR are not necessary for competent client to refuse care. A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates client's protein status for the longest length of time? - correct answers.Serum albumin Rationale: Serum albumin has a long half-life. What client statement indicates to the nurse that the client requires assistance with bathing? - correct answers."I don't understand why I'm so weak & tired." How should the nurse handle linens that are soiled with incontinent feces? - correct answers.Place the soiled linens in a pillow case & deposit them in the dirty linen hamper When caring for an immobile client, what nursing diagnosis has the highest priority? - correct answers.Impaired gas exchange The nurse assesses an immobile, elderly male client & determines that his blood pressure is 138/60, his temperature is 95.8F & his output is 100 mL of concentrated urine during the last hour. He has wet sounding lungs & increased respiratory secretions. Based on these assessment findings , what nursing action is most important for the nurse to implement? - correct answers.Turn the client q2h Rationale: It will help move & drain respiratory secretions & prevent pneumonia from occurring. The home health nurse visits an elderly female client who had a brain attack 3 months ago & is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care? - correct answers.The nurse notes there are numerous scatter rugs throughout the house The nurse removes the dressing on a client's heel that is cover a pressure sore 1" in diameter & finds that there is straw-colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record? - correct answers.One-inch pressure sore draining serous fluid Medication is prescribed to be given QID. What schedule should the nurse use to administer this Rx? - correct answers.0800, 1200, 1600, 2000 The nurse working in the ED is assessing 4 clients' ability to tolerate pain. Which client is likely to tolerate a higher level of pain? - correct answers.1 55y/o woman who has had moderate low back pain for 3 months Rationale: Experiences with the same type of pain that has successfully been relieved makes it easier for the client to interpret the pain sensation and, as a result, the client is better prepared to take steps to relieve the pain. All other clients are having new experiences with pain. A 4y/o boy who is scheduled for a tonsillectomy & adenoidectomy asks the nurse, "Will it hurt to have my tonsils & adenoids taken out?" Which response is best for the nurse to provide? - correct answers."It may hurt, but we'll give you medicine to help you feel better." A low-sodium, low-protein diet is prescribed for a 45y/o client with renal insufficiency & HTN, who gained 3lbs in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from the 24hr diet recall? - correct answers.1. Snack of potato chips & diet soda 2. Lunch of tuna, carrots, fruit & coffee 3. Breakfast of eggs, bacon, toast & coffee 4. Bedtime snack of crackers & milk What intervention should the nurse include in the care plan for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency? - correct answers.Check capillary refill of toes on lower extremity with Unna's paste boot Rationale: Boot becomes rigid after it dries, so it is important to check distally for adequate circulation. No bandage should be put under it. Should be applied from foot & wrapped towards knee. Acts as a sterile dressing & should not be removed q8h. Weekly removal is reasonable. Male client with nursing diagnosis of "spiritual distress". What intervention is best for the nurse to implement when caring for this client? - correct answers.Use reflective listening techniques when the client expresses spiritual doubts. Rationale: Client should be consulted before involving chaplain.