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HESI Fundamentals Practice
A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action
has the highest priority?
Ensure cultural customs are observed.
Increase oxygen flow to 4L/minute.
Auscultate bilateral lung fields.
Inform the family that death is imminent.
Inform
An audible gurgling sound produced by a dying client is characteristic of ineffective clearance of
secretions from the lungs or upper airways, causing a "rattling" sound as air moves through the
accumulated fluid. The nursing priority in this situation is to convey to the family that the
client's death is imminent (D). Although culturally sensitive care should be observed throughout
the client's plan of care (A), this is not the priority at this time. Administration of oxygen may be
expected care, but a flow rate greater than 2 L/minute (B) is not palliative care. (C) may provide
additional information, but is not necessary as death approaches.
As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy in the
treatment room, he cries continuously. What intervention should the nurse implement?
Take the child back to his room.
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Recruit others to restrain the child.
Ask the mother to be present to soothe the child.
Show the child how to manipulate the equipment.
soothe
A 4-year-old typically has a vivid imagination and lacks concrete thinking abilities. The mother's
assistance (C) can provide a stabilizing presence to help soothe the preschooler, who may
perceive the invasive procedure as mutilating. To preserve the child's sense of security
associated with the hospital room, it is best to perform difficult or painful procedures in
another area (A). (B) may be necessary to prevent injury if the child is unable to cooperate with
the mother's coaxing. (D) is best done before going to the treatment room when the child feels
less threatened.
Which client assessment data is most important for the nurse to consider before ambulating a
postoperative client?
Respiratory rate.
Wound location.
Pedal pulses.
Pain rating.
Respiratory rate
Mobilization and ambulation increase oxygen use, so it is most important to assess the client's
respiratory rate (A) before ambulation to determine tolerance for activity. (B, C, and D) are also
important, but are of lower priority than (A).
A client provides the nurse with information about the reason for seeking care. The nurse
realizes that some information about past hospitalizations is missing. How should the nurse
obtain this information?
Solicit information on hospitalization from the insurance company.
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HESI Fundamentals Practice
A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action
has the highest priority?
Ensure cultural customs are observed.
Increase oxygen flow to 4L/minute.
Auscultate bilateral lung fields.
Inform the family that death is imminent.
Inform
An audible gurgling sound produced by a dying client is characteristic of ineffective clearance of
secretions from the lungs or upper airways, causing a "rattling" sound as air moves through the
accumulated fluid. The nursing priority in this situation is to convey to the family that the
client's death is imminent (D). Although culturally sensitive care should be observed throughout
the client's plan of care (A), this is not the priority at this time. Administration of oxygen may be
expected care, but a flow rate greater than 2 L/minute (B) is not palliative care. (C) may provide
additional information, but is not necessary as death approaches.
As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy in the
treatment room, he cries continuously. What intervention should the nurse implement?
Take the child back to his room.
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Recruit others to restrain the child.
Ask the mother to be present to soothe the child.
Show the child how to manipulate the equipment.
soothe
A 4-year-old typically has a vivid imagination and lacks concrete thinking abilities. The mother's
assistance (C) can provide a stabilizing presence to help soothe the preschooler, who may
perceive the invasive procedure as mutilating. To preserve the child's sense of security
associated with the hospital room, it is best to perform difficult or painful procedures in
another area (A). (B) may be necessary to prevent injury if the child is unable to cooperate with
the mother's coaxing. (D) is best done before going to the treatment room when the child feels
less threatened.
Which client assessment data is most important for the nurse to consider before ambulating a
postoperative client?
Respiratory rate.
Wound location.
Pedal pulses.
Pain rating.
Respiratory rate
Mobilization and ambulation increase oxygen use, so it is most important to assess the client's
respiratory rate (A) before ambulation to determine tolerance for activity. (B, C, and D) are also
important, but are of lower priority than (A).
A client provides the nurse with information about the reason for seeking care. The nurse
realizes that some information about past hospitalizations is missing. How should the nurse
obtain this information?
Solicit information on hospitalization from the insurance company.
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