BSN 225 HESI RN Specialty
Fundamentals of Nursing Final
Exam (Latest Update )
Questions & Answers |100% Correct
| Grade A - Nightingale
Question:
The adult daughter of an older client has been instructed on how to
administer insulin to the client. Which observation indicates that the nurse
needs to provide further instructions to the daughter?
a. air is injected into the insulin vial before withdrawing the prescribed
amount
b. alcohol swab is used to cleanse the skin before injecting
c. the area of the injection is not massaged after administering the injection
d. the deltoid muscle region is selected as the site for injection
Answer:
d. the deltoid muscle region is selected as the site for injection
Rationale:
Insulin should be administered into the subQ tissue and not the muscle.
,Question:
During morning report the night nurse reports that an 86-year-old client
often becomes confused, anxious, or is found pacing their room overnight.
The client is also intermittently disoriented to date, time, and/or place. Based
on this client's behavior, which intervention should the day nurse
implement> (Select all that apply).
a. obtain a prescription for melatonin or another sleep aid.
b. ensure the client's room is dark and quiet during sleep hours.
c. limit stimulating food, drink, or activities in the late afternoon and evening
hours
d. keep the client active during the day with ambulation as tolerated and
structured activities
e. establish a predictable daily routine that includes bedtime, waking, meals,
and daily activities.
Answer:
c. limit stimulating food, drink, or activities in the late afternoon and evening
hours
d. keep the client active during the day with ambulation as tolerated and
structured activities
e. establish a predictable daily routine which includes bedtime, waking,
meals, and daily activities.
Rationale:
Management of sundowning behavior is targeted toward establishing
routines, providing an environment suited to sleeping, and easing the
symptoms of sundowning.
,Question:
The nurse establishes the nursing diagnosis of "impaired activity tolerance"
for a client in an acute rehab facility who is recovering from hemicolectomy
with colostomy surgery. What did the nurse observe?
a. client asks spouse to perform stoma care and assist with feeding
b. client rates pain score as 8/10 during physical therapy
c. client's heart rate remains elevated 5 minutes after returning from the
bathroom
d. client refuses to participate in scheduled group activities.
Answer:
c. client's heart rate remains elevated 5 minutes after returning from the
bathroom
Rationale:
An elevated heart rate that remains elevated 5 minutes after completing an
activity of mild intensity, such as ambulating to the bathroom, is an objective
sign of activity intolerance.
Question:
PAST MEDICAL HX
Type II DM
Stage 3 chronic kidney disease
HTN
Hyperlipidemia
Osteoarthritis
, Constipation
MEDICATIONS
Metformin 1000 mg PO q12h
Naproxen 250 mg PO q6h PRN
Spironolactone 50 mg PO qday
Captopril 75 mg PO bid
Pravastatin 40 mg PO qday
Psyllium 5 grams PO qday
The nurse is reviewing appropriate food selections with a client. Which food
item should the nurse encourage the client to remove from their lunch tray?
a. steamed spinach
b. baked chicken
c. whole kernel corn
d. medium-size apple
Answer:
a. steamed spinach
Rationale:
Evaluation of the client's lunch choices reveals a portion of steamed spinach.
Steamed spinach is high in potassium should be removed from the client's
lunch tray.
Fundamentals of Nursing Final
Exam (Latest Update )
Questions & Answers |100% Correct
| Grade A - Nightingale
Question:
The adult daughter of an older client has been instructed on how to
administer insulin to the client. Which observation indicates that the nurse
needs to provide further instructions to the daughter?
a. air is injected into the insulin vial before withdrawing the prescribed
amount
b. alcohol swab is used to cleanse the skin before injecting
c. the area of the injection is not massaged after administering the injection
d. the deltoid muscle region is selected as the site for injection
Answer:
d. the deltoid muscle region is selected as the site for injection
Rationale:
Insulin should be administered into the subQ tissue and not the muscle.
,Question:
During morning report the night nurse reports that an 86-year-old client
often becomes confused, anxious, or is found pacing their room overnight.
The client is also intermittently disoriented to date, time, and/or place. Based
on this client's behavior, which intervention should the day nurse
implement> (Select all that apply).
a. obtain a prescription for melatonin or another sleep aid.
b. ensure the client's room is dark and quiet during sleep hours.
c. limit stimulating food, drink, or activities in the late afternoon and evening
hours
d. keep the client active during the day with ambulation as tolerated and
structured activities
e. establish a predictable daily routine that includes bedtime, waking, meals,
and daily activities.
Answer:
c. limit stimulating food, drink, or activities in the late afternoon and evening
hours
d. keep the client active during the day with ambulation as tolerated and
structured activities
e. establish a predictable daily routine which includes bedtime, waking,
meals, and daily activities.
Rationale:
Management of sundowning behavior is targeted toward establishing
routines, providing an environment suited to sleeping, and easing the
symptoms of sundowning.
,Question:
The nurse establishes the nursing diagnosis of "impaired activity tolerance"
for a client in an acute rehab facility who is recovering from hemicolectomy
with colostomy surgery. What did the nurse observe?
a. client asks spouse to perform stoma care and assist with feeding
b. client rates pain score as 8/10 during physical therapy
c. client's heart rate remains elevated 5 minutes after returning from the
bathroom
d. client refuses to participate in scheduled group activities.
Answer:
c. client's heart rate remains elevated 5 minutes after returning from the
bathroom
Rationale:
An elevated heart rate that remains elevated 5 minutes after completing an
activity of mild intensity, such as ambulating to the bathroom, is an objective
sign of activity intolerance.
Question:
PAST MEDICAL HX
Type II DM
Stage 3 chronic kidney disease
HTN
Hyperlipidemia
Osteoarthritis
, Constipation
MEDICATIONS
Metformin 1000 mg PO q12h
Naproxen 250 mg PO q6h PRN
Spironolactone 50 mg PO qday
Captopril 75 mg PO bid
Pravastatin 40 mg PO qday
Psyllium 5 grams PO qday
The nurse is reviewing appropriate food selections with a client. Which food
item should the nurse encourage the client to remove from their lunch tray?
a. steamed spinach
b. baked chicken
c. whole kernel corn
d. medium-size apple
Answer:
a. steamed spinach
Rationale:
Evaluation of the client's lunch choices reveals a portion of steamed spinach.
Steamed spinach is high in potassium should be removed from the client's
lunch tray.
