NURS 310 HESI Practice Fundamentals Exam

An older client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? Massage any reddened areas for at least five minutes. Encourage active range of motion exercises on extremities. Position the client laterally, prone, and dorsally in sequence. Gently lift the client when moving into a desired position. - Gently lift the client when moving into a desired position. On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? Assault. Battery. Malpractice. False imprisonment. - Battery. Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching).Performing any procedure against the client's wishes can potentially create a legal issue, such as battery, even if the procedure is of questionable benefit to the client. A client who is in hospice care reports increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? Give an around-the-clock schedule for administration of analgesics. Administer analgesic medication as needed when the pain is severe. Provide medication to keep the client sedated and unaware of stimuli. Offer a medication-free period so that the client can do daily activities. - Give an around-the-clock schedule for administration of analgesics. A Sub-Saharan African widowed immigrant woman lives with her deceased husband's brother and his family, which includes the brother-in-law's children and the widow's adult children. Each family member speaks fluent English. Surgery is recommended for this client. What is the best plan to obtain consent for surgery for this client? Obtain an interpreter to explain the procedure to the client. Encourage the client to make her own decision regarding surgery. Ask the family members to provide a clarification of the surgeon's explanation to the client. Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow. - Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow. Customary law in some rural sub-Saharan countries encompasses wife inheritance and polygamy; the widow becomes the inherited wife of the her husband's brother. In those rural areas women live in a patriarchal family where decisions are made by men. Most likely, the brother-in-law will make the decision for his inherited wife, so it is important to provide the surgeon with culturally sensitive information. Since all family members speak fluent English, there is no need for a translator. It is culturally insensitive to encourage the woman to go against her wishes to follow her cultural worldview. The nurse is examining a male client who reports itching on his right arm, The nurse observes a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. Several areas of red, papular lesions from pinpoint to 0.5 cm in size. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. - Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance rather than simply naming the condition. Vesicles are fluid-filled blisters. Papules are solid elevated lesions and petechiae are pinpoint red to purple skin discolorations that do not itch. A male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? "It is important that you continue your medication while learning to meditate." "Spiritual meditation requires a time commitment of 15 to 20 minutes daily." "Obtain your healthcare provider's permission before starting meditation." "Complementary therapy and western medicine can be effective for you." - "It is important that you continue your medication while learning to meditate." The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? "If I exercise at least two times weekly for one hour, I will lower my cholesterol." "I need to avoid eating proteins, including red meat." "I will limit my intake of beef to 4 ounces per week." "My blood level of low density lipoproteins needs to increase." - "I will limit my intake of beef to 4 ounces per week." The nurse is evaluating a client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? Multiple choice question Tossed salad, low-sodium dressing, bacon and tomato sandwich. New England clam chowder, no-salt crackers, fresh fruit salad. Skim milk, turkey salad, roll, vanilla ice cream. Macaroni and cheese, diet Coke, a slice of cherry pie. - Skim milk, turkey salad, roll, vanilla ice cream. Skim milk, turkey, bread, and ice cream, while containing some sodium, are considered low-sodium foods. Bacon, canned soups (especially those with seafood), hard cheeses, macaroni, and most diet drinks are very high in sodium. Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? Reassure the client that he will become accustomed to the stoma appearance in time. Instruct the client that the stoma will become smaller when the initial swelling diminishes. Offer to contact a member of the local ostomy support group to help him with his concerns. Encourage the client to handle the stoma equipment to gain confidence with the procedure. - Instruct the client that the stoma will become smaller when the initial swelling diminishes. What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? It is more difficult to find a superficial vein in the feet and ankles. A decreased flow rate could result in the formation of a thrombosis. A cannulated extremity is more difficult to move when the leg or foot is used. Veins are located deep in the feet and ankles, resulting in a more painful procedure. - A decreased flow rate could result in the formation of a thrombosis. Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation which, if dislodged, could be life-threatening. Superficial veins are often very easy to find in the feet and legs. Handling a leg or foot with an IV is probably not any more difficult than handling an arm or hand. Even if the nurse believes moving a cannulated leg is more difficult, this is not the most important reason for using the upper extremities. Pain is not a consideration. A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV every 24 hours is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? Contact the healthcare provider and complete a medication variance form. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. Notify the charge nurse and complete an incident report to explain the missed dose. Give the missed dose at 1300 and change the schedule to administer daily at 1300. - Give the missed dose at 1300 and change the schedule to administer daily at 1300. During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem? Restatement of responses. Open-ended questions. Closed-ended questions. Problem-seeking responses. - Closed-ended questions Lay descriptors of health problems can be vague and nonspecific. To efficiently obtain specific information, the nurse should use closed-ended questions that focus on common signs and symptoms about a client's health problem.Other question types are used when therapeutically interacting and should be used after specific information is obtained from the client. An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? Generalized dry skin. Localized dry skin on lower extremities. Red flush over entire skin surface. Rashes in the axillary, groin, and skin fold regions. - Rashes in the axillary, groin, and skin fold regions. Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes (D), skin breakdown, and the development of pressure ulcers. (A, B, and C) do not address the concepts of inflammation and tissue integrity. After completing an assessment and determining that a client has a problem, which action should the nurse perform next? Determine the etiology of the problem. Prioritize nursing care interventions. Plan appropriate interventions. Collaborate with the client to set goals. - Determine the etiology of the problem. Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? Chocolate pudding. Graham crackers. Sugar free gelatin. Apple slices. - Chocolate pudding. The client with myasthenia gravis is at high risk for altered nutrition because of fatigue and muscle weakness resulting in dysphagia. Snacks that are semisolid, such as pudding are easy to swallow, require minimal chewing effort, and provide calories and protein.Gelatin does not provide any nutritional value and the other options require energy to chew and are more difficult to swallow than pudding. Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? "That means you have derived the maximum benefit, and the heat can be removed." "Your blood vessels are becoming dilated and removing the heat from the site." "We will increase the temperature 5 degrees when the pad no longer feels warm." "The body's receptors adapt over time as they are exposed to heat." - "The body's receptors adapt over time as they are exposed to heat." An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? Inquire about the source and type of pain. Examine the nose for congestion and discharge. Take vital signs for temperature elevation. Explore the abdominal area for distension. - Inquire about the source and type of pain. A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? Record the coughing incident. No further action is required at this time. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. - After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. When conducting an admission assessment, the nurse should ask the client about the use of complementary healing practices. Which statement is accurate regarding the use of these practices? Complementary healing practices interfere with the efficacy of the medical model of treatment. Conventional medications are likely to interact with folk remedies and cause adverse effects. Many complementary healing practices can be used in conjunction with conventional practices. Conventional medical practices will ultimately replace the use of complementary healing practices. - Many complementary healing practices can be used in conjunction with conventional practices. The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? Avoid any types of sprays, powders, and perfumes. Wearing a mask while cleaning will not help to avoid allergens. Purchase any type of clothing, but be sure it is washed before wearing it. Pollen count is related to hay fever, not to allergens. - Avoid any types of sprays, powders, and perfumes. The client with allergies should be instructed to reduce any exposure to pollen, dust, fumes, odors, sprays, powders, and perfumes. The client should be encouraged to wear a mask when working around dust or pollen. Clients with allergies should avoid any clothing that causes itching; washing clothes will not prevent an allergic reaction to some fabrics. Pollen count is related to allergens, and the client should be instructed to stay indoors when the pollen count is high. The nurse is developing a plan of care for a client with dementia. Which feature of confusion in the elderly is accurate? Bewilderment is to be expected, and progresses with age. Disorientation often follows relocation to new surroundings. Uncertainty is a result of irreversible brain pathology. Being perplexed can be prevented with adequate sleep. - Disorientation often follows relocation to new surroundings. The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment? Client. Healthcare provider. A family member. Previous medical records. - Client. A primary source of information for a health assessment is the client. Family members, the medical record, and the healthcare provider are considered secondary sources about the client's health history, but other details, such as subjective data, can only be provided directly from the client. A client's spouse is learning passive range-of-motion for the client's contracted shoulder. The nurse observes that the spouse is holding the client's arm above and below the elbow. Which nursing action should the nurse implement? Acknowledge that the spouse is supporting the arm correctly. Encourage the spouse to keep the joint covered to maintain warmth. Reinforce the need to grip directly under the joint for better support. Instruct the spouse to grip directly over the joint for better motion. - Acknowledge that the spouse is supporting the arm correctly. An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? Position the client on the right side of the bed in reverse Trendelenburg. Fill the enema container with 1000 mL of warm water and 5 mL of castile soap. Reposition in a Sims' position with the client's weight on the anterior ilium. Raise the side rails on both sides of the bed and elevate the bed to waist level. - Reposition in a Sims' position with the client's weight on the anterior ilium. The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? Thalamus. Hypothalamus. Frontal lobe. Parietal lobe. - Frontal lobe. Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? Apply a condom catheter. Apply a skin protectant. Encourage increased fluid intake. Assess for bladder distention. - Assess for bladder distention.