HESI A2 CRIOTICAL THINKING

HESI A2 CRIOTICAL THINKING 1. A client who is in hospice care complains of 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. 2. The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? Flush the tube with water. 3. An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? Gently lift the client when moving into a desired position. 4. When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? Loosen the right wrist restraint. 5. The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A lactating woman nursing her 3-day-old infant. 6. A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? Give the missed dose at 1300 and change the schedule to administer daily at 1300. 7. While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? Acknowledge that she is supporting the arm correctly. 8. What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A decreased flow rate could result in the formation of a thrombosis. 9. The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? Reassess the client's blood pressure using a larger cuff. This study source was downloaded by from CourseH on :22:10 GMT -06:00 10. 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? The body's receptors adapt over time as they are exposed to heat. 11. 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? I will limit my intake of beef to 4 ounces per week. 12. The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? Move the chair parallel to the right side of the bed, and stand the client on the right foot. 13. 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? Reposition in a Sim's position with the client's weight on the anterior ilium. 14. A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? Blood transfusions are forbidden. 15. The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? Observe the appearance of the skin under the ice pack. 16. 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? After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. 17. A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? 8 a.m., 4 p.m., and midnight. 18. A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump? To calculate this problem correctly, remember that the dose of KCl is not used in the calculation. 250 ml/4 hours = 63 ml/hour. This study source was downloaded by from CourseH on :22:10 GMT -06:00 19. An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? Be sure to have a complete physical examination before beginning your planned exercise program. 20. The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? During the inhalation. 21. Which action is most important for the nurse to implement when donning sterile gloves? Keep gloved hands above the elbows.