HESI RN FUNDAMENTALS PREVIEW QUESTIONS

• The nurse is discharging an adult woman who was hospitalized for 5 days for treatment of pneumonia. While the nurse is reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse to implement? Provide written instructions that are easy to follow. • Which assessment finding is most significant in determining the level of assistance a client needs with personal care? Disorientation to time, place, and person • Eight hours after the removal of an indwelling catheter, a male client reports low abdominal pain, and palpation of the bladder indicates that it is distended and dull percussion. Even after assistingthe client to a standing position, he is unable to void. What action should the nurse take? Prepare to reinsert the urinary catheter. • The nurse notices a male client grimacing as he moves from the bed to a chair, but when asked about his pain he denies having any pain. Which intervention should the nurse implement first? Askthe client what is making him grimace. • The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first? Respiratory rate • The charge nurse observes a new graduate nurse demonstrate the administration of two differentliquid medications through a gastrostomy tube used for continuous feeding, as seen in the video. What actions should the nurse take? (SATA) Confirm that the nurse determined the amount of gastric residual Add the liquid volumes when documenting fluid intake Instruct the nurse to administer each mediation separately • The nurse inserts a catheter for nasotrachealsuctioning asseen in the picture. What action shouldthe nurse take nest? Apply intermittent suction