HESI 1
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Before administering a client's Document the events that occurred in the nurses'
medication, the nurse assesses a notes.
change in the client's condition and
decides to withhold the medication
until consulting with the healthcare
provider. After consultation with the
healthcare provider, the dose of the
medication is changed and the nurse
administers the newly prescribed
dose an hour later than the originally
scheduled time. What action should
the nurse implement in response to
this situation?
Notify the charge nurse that a
medication error occurred.
Submit a medication variance report
to the supervisor.
Document the events that occurred
in the nurses' notes.
Discard the original medication
administration record.
,A male client with venous Increase in pulse rate.
incompetence stands up and his
blood pressure subsequently drops.
Which finding should the nurse
identify as a compensatory
response?
Bradycardia.
Increase in pulse rate.
Peripheral vasodilation.
Increase in cardiac output.
Which nursing intervention is most Obtain a prescription for removal of the catheter as
beneficial in reducing the risk of soon as possible
urosepsis in a hospitalized client with
an indwelling urinary catheter?
Ensure that the client's perineal area
is cleansed twice a day.
Maintain accurate documentation of
the fluid intake and output.
Encourage frequent ambulation if
allowed or regular turning if on
bedrest.
Obtain a prescription for removal of
the catheter as soon as possible
,A client is admitted to the hospital Take measures to promote as much comfort as
with intractable pain. What possible.
instruction should the nurse provide
the unlicensed assistive personnel
(UAP) who is preparing to assist this
client with a bed bath?
Take measures to promote as much
comfort as possible.
Report any signs of drug addiction
to the nurse immediately.
Wait until the client's pain is gone
before assisting with personal care.
This client's pain will be difficult to
manage, since the cause is unknown.
Which statement correctly identifies Upon discharge, the client will list three ways to
a written learning objective for a protect the feet from injury.
client with peripheral vascular
disease?
The nurse will provide client
instruction for daily foot care.
The client will demonstrate proper
trimming toenail technique.
Upon discharge, the client will list
three ways to protect the feet from
injury.
After instruction, the nurse will
ensure the client understands foot
care rationale.
, A male client has a nursing diagnosis Use reflective listening techniques when the client
of "spiritual distress." What expresses spiritual doubts.
intervention is best for the nurse to
implement when caring for this
client?
Use distraction techniques during
times of spiritual stress and crisis.
Reassure the client that his faith will
be regained with time and support.
Consult with the staff chaplain and
ask that the chaplain visit with the
client.
Use reflective listening techniques
when the client expresses spiritual
doubts.
A client has a nursing diagnosis of, Assist and support the client in establishing short-
"Spiritual distress related to a loss of term goals.
hope, secondary to impending
death." What intervention is best for
the nurse to implement when caring
for this client?
Help the client to accept the final
stage of life.
Assist and support the client in
establishing short-term goals.
Encourage the client to make future
plans, even if they are unrealistic.
Instruct the client's family to focus on
positive aspects of the client's life
Leave the first rating
Save
Terms in this set (81) Hide definitions
Before administering a client's Document the events that occurred in the nurses'
medication, the nurse assesses a notes.
change in the client's condition and
decides to withhold the medication
until consulting with the healthcare
provider. After consultation with the
healthcare provider, the dose of the
medication is changed and the nurse
administers the newly prescribed
dose an hour later than the originally
scheduled time. What action should
the nurse implement in response to
this situation?
Notify the charge nurse that a
medication error occurred.
Submit a medication variance report
to the supervisor.
Document the events that occurred
in the nurses' notes.
Discard the original medication
administration record.
,A male client with venous Increase in pulse rate.
incompetence stands up and his
blood pressure subsequently drops.
Which finding should the nurse
identify as a compensatory
response?
Bradycardia.
Increase in pulse rate.
Peripheral vasodilation.
Increase in cardiac output.
Which nursing intervention is most Obtain a prescription for removal of the catheter as
beneficial in reducing the risk of soon as possible
urosepsis in a hospitalized client with
an indwelling urinary catheter?
Ensure that the client's perineal area
is cleansed twice a day.
Maintain accurate documentation of
the fluid intake and output.
Encourage frequent ambulation if
allowed or regular turning if on
bedrest.
Obtain a prescription for removal of
the catheter as soon as possible
,A client is admitted to the hospital Take measures to promote as much comfort as
with intractable pain. What possible.
instruction should the nurse provide
the unlicensed assistive personnel
(UAP) who is preparing to assist this
client with a bed bath?
Take measures to promote as much
comfort as possible.
Report any signs of drug addiction
to the nurse immediately.
Wait until the client's pain is gone
before assisting with personal care.
This client's pain will be difficult to
manage, since the cause is unknown.
Which statement correctly identifies Upon discharge, the client will list three ways to
a written learning objective for a protect the feet from injury.
client with peripheral vascular
disease?
The nurse will provide client
instruction for daily foot care.
The client will demonstrate proper
trimming toenail technique.
Upon discharge, the client will list
three ways to protect the feet from
injury.
After instruction, the nurse will
ensure the client understands foot
care rationale.
, A male client has a nursing diagnosis Use reflective listening techniques when the client
of "spiritual distress." What expresses spiritual doubts.
intervention is best for the nurse to
implement when caring for this
client?
Use distraction techniques during
times of spiritual stress and crisis.
Reassure the client that his faith will
be regained with time and support.
Consult with the staff chaplain and
ask that the chaplain visit with the
client.
Use reflective listening techniques
when the client expresses spiritual
doubts.
A client has a nursing diagnosis of, Assist and support the client in establishing short-
"Spiritual distress related to a loss of term goals.
hope, secondary to impending
death." What intervention is best for
the nurse to implement when caring
for this client?
Help the client to accept the final
stage of life.
Assist and support the client in
establishing short-term goals.
Encourage the client to make future
plans, even if they are unrealistic.
Instruct the client's family to focus on
positive aspects of the client's life
