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
4.
During the admission assessment of a terminally ill male client, the client states that
he is an agnostic. What is the best nursing action in response to this statement?
-document the statement in the client’s spiritual assessment
5.
The nurse observes a newly admitted older adult female take short steps and walk
very slowly while pushing a walker in front of her. What action should the nurse take
in response to these observations?
-complete a full fall risk assessment of the client
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
https://www.coursehero.com/file/131565269/2-HESI-FUNDAMENTALS-RN-47-TEST-BANK-Qpdf/
, 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
This study source was downloaded by 100000864809617 from CourseHero.com on 04-04-2023 22:17:14 GMT -05:00
https://www.coursehero.com/file/131565269/2-HESI-FUNDAMENTALS-RN-47-TEST-BANK-Qpdf/
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
4.
During the admission assessment of a terminally ill male client, the client states that
he is an agnostic. What is the best nursing action in response to this statement?
-document the statement in the client’s spiritual assessment
5.
The nurse observes a newly admitted older adult female take short steps and walk
very slowly while pushing a walker in front of her. What action should the nurse take
in response to these observations?
-complete a full fall risk assessment of the client
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
https://www.coursehero.com/file/131565269/2-HESI-FUNDAMENTALS-RN-47-TEST-BANK-Qpdf/
, 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
This study source was downloaded by 100000864809617 from CourseHero.com on 04-04-2023 22:17:14 GMT -05:00
https://www.coursehero.com/file/131565269/2-HESI-FUNDAMENTALS-RN-47-TEST-BANK-Qpdf/
