HESI FUNDAMENTALS PRACTICE EXAM 1. QUESTIONS AND ANSWERS.

81. In evaluating client care, which action should the nurse take first? 82. When assessing client with nursing dx of fluid volume deficit, the nurse notes that the client's skin over sternum "tents" when gently pinched. Which action should the nurse implement? 83. Prior to administering newly prescribed medication, nurse reviews adverse effects & determines priority risks to the client. While performing this action, nurse is engaged in which step of the nursing process? 84. When teaching female client to perform intermittent self-catheterization, the nurse should ensure client's ability to perform which action? Locate the perineum 85. Nurse determines client's IV solution is infusing at 250 mL/hr. Prescribed rate is 125 mL/hr. What action should the nurse take first? Slow the IV infusion to keep vein open (KVO) rate Rationale: Should change flow rate to KVO to prevent further risk of fluid volume overload, then gather additional assessment data, such as when the IV solution was started & appearance of IV site before contacting HCP 86. Male nurse is assigned to care for female Muslim client. When nurse offers to bathe the client, the client requests that a female nurse perform this task. How should the male nurse respond? 87. As the nurse prepares the equipment to be used to start an IV on a 4y/o boy in the treatment room, he cries continuously. What intervention should the nurse implement? 88. Client in hospice care develops audible gurgling sounds on inspiration. Which nursing action has highest priority? 89. Nurse notes that client consistently coughs when eating & drinking. Which nursing diagnosis is most important for the nurse to include in patient's care plan? 90. When making bed of a client who needs a bed cradle, which action should the nurse include?