NURS 310 HESI Practice Exam. Correctly answered.

An older client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? Massage any reddened areas for at least five minutes. Encourage active range of motion exercises on extremities. Position the client laterally, prone, and dorsally in sequence. Gently lift the client when moving into a desired position. - Gently lift the client when moving into a desired position. On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? Assault. Battery. Malpractice. False imprisonment. - Battery. Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching).Performing any procedure against the client's wishes can potentially create a legal issue, such as battery, even if the procedure is of questionable benefit to the client. A client who is in hospice care reports 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. Administer analgesic medication as needed when the pain is severe. Provide medication to keep the client sedated and unaware of stimuli. Offer a medication-free period so that the client can do daily activities. - Give an aroundthe- clock schedule for administration of analgesics. A Sub-Saharan African widowed immigrant woman lives with her deceased husband's brother and his family, which includes the brother-in-law's children and the widow's adult children. Each family member speaks fluent English. Surgery is recommended for this client. What is the best plan to obtain consent for surgery for this client? Obtain an interpreter to explain the procedure to the client. Encourage the client to make her own decision regarding surgery. Ask the family members to provide a clarification of the surgeon's explanation to the client. Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow. - Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow. Customary law in some rural sub-Saharan countries encompasses wife inheritance and polygamy; the widow becomes the inherited wife of the her husband's brother. In those rural areas women live in a patriarchal family where decisions are made by men. Most likely, the brother-in-law will make the decision for his inherited wife, so it is important to provide the surgeon with culturally sensitive information. Since all family members speak fluent English, there is no need for a translator. It is culturally insensitive to encourage the woman to go against her wishes to follow her cultural worldview. The nurse is examining a male client who reports itching on his right arm, The nurse observes a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. Several areas of red, papular lesions from pinpoint to 0.5 cm in size. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. - Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance rather than simply naming the condition. Vesicles are fluid-filled blisters. Papules are solid elevated lesions and petechiae are pinpoint red to purple skin discolorations that do not itch. A male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? "It is important that you continue your medication while learning to meditate." "Spiritual meditation requires a time commitment of 15 to 20 minutes daily." "Obtain your healthcare provider's permission before starting meditation." "Complementary therapy and western medicine can be effective for you." - "It is important that you continue your medication while learning to meditate." 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? "If I exercise at least two times weekly for one hour, I will lower my cholesterol." "I need to avoid eating proteins, including red meat." "I will limit my intake of beef to 4 ounces per week." "My blood level of low density lipoproteins needs to increase." - "I will limit my intake of beef to 4 ounces per week." The nurse is evaluating a client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? Multiple choice question Tossed salad, low-sodium dressing, bacon and tomato sandwich. New England clam chowder, no-salt crackers, fresh fruit salad. Skim milk, turkey salad, roll, vanilla ice cream. Macaroni and cheese, diet Coke, a slice of cherry pie. - Skim milk, turkey salad, roll, vanilla ice cream. Skim milk, turkey, bread, and ice cream, while containing some sodium, are considered low-sodium foods. Bacon, canned soups (especially those with seafood), hard cheeses, macaroni, and most diet drinks are very high in sodium. Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? Reassure the client that he will become accustomed to the stoma appearance in time. Instruct the client that the stoma will become smaller when the initial swelling diminishes. Offer to contact a member of the local ostomy support group to help him with his concerns. Encourage the client to handle the stoma equipment to gain confidence with the procedure. - Instruct the client that the stoma will become smaller when the initial swelling diminishes. What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? It is more difficult to find a superficial vein in the feet and ankles. A decreased flow rate could result in the formation of a thrombosis. A cannulated extremity is more difficult to move when the leg or foot is used. Veins are located deep in the feet and ankles, resulting in a more painful procedure. - A decreased flow rate could result in the formation of a thrombosis. Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation which, if dislodged, could be life-threatening. Superficial veins are often very easy to find in the feet and legs. Handling a leg or foot with an IV is probably not any more difficult than handling an arm or hand. Even if the nurse believes moving a cannulated leg is more difficult, this is not the most important reason for using the upper extremities. Pain is not a consideration. A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV every 24 hours is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? Contact the healthcare provider and complete a medication variance form. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. Notify the charge nurse and complete an incident report to explain the missed dose. Give the missed dose at 1300 and change the schedule to administer daily at 1300. - Give the missed dose at 1300 and change the schedule to administer daily at 1300. During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem? Restatement of responses. Open-ended questions. Closed-ended questions. Problem-seeking responses. - Closed-ended questions Lay descriptors of health problems can be vague and nonspecific. To efficiently obtain specific information, the nurse should use closed-ended questions that focus on common signs and symptoms about a client's health problem.Other question types are used when therapeutically interacting and should be used after specific information is obtained from the client.