Answers latest update 2022/2023
To assess the quality of an adult client’s pain, what approach should the nurse use? C
A) Observe body language and movement.
B) Provide a numeric pain scale.
C) Ask the client to describe the pain.
D) Identify effective pain relief measures.
A client who has been diagnosed with terminal cancer tells the nurse, “The doctor
told me I have cancer and do not have long to live.” Which response is best for
the nurse to provide?
A) “That’s correct, you do not have long to live” D
B) “Would you like me to call your minister?”
C) “Don't give up, you still have chemotherapy to try.”
D) “Yes, your condition is serious.”
When performing blood pressure measurement to assess for orthostatic
hypotension, which action should the nurse implement first? C
A) Apply the blood pressure cuff securely.
B) Record the client’s pulse rate
and rhythm. C) Position the
client supine for a few minutes.
D) Assist the client to stand at bedside.
Female unlicensed assistive personnel (UAP) are assigned to take the vital signs
of a client with pertussis for whom droplet precautions have been implemented.
The UAP request a change in assignment, stating she has not yet been fitted for a
HESI RN FUNDAMENTALS TESTBANK Exam Questions and
Answers latest update 2022/2023
,HESI RN FUNDAMENTALS TESTBANK Exam Questions and
Answers latest update 2022/2023
particulate filter mask. What action should the nurse take? D
When evaluating the effectiveness of a client’s nursing care, the nurse first
reviews the expected outcomes identified in the plan of care. What action should
the nurse take next?
A) Modify the nursing interventions to achieve the client’s goals.
B) Determine if the expected outcomes were realistic.
C) Review related professional standards of care.
D) Obtain current client data to compare with expected outcomes.
A policy requiring the removal of acrylic nails by all nursing personnel was
implemented six months ago. Which assessment measure best determines if the
intended outcome of the policy is being achieved?
A) Number of the staff-induced skin injuries.
B) Client satisfaction survey.
C) Rate of needlestick injuries by nurses.
D) Healthcare-associated infection rates.
A client with limited tolerance for activity needs to walk in the hallway with
assistance. Which instructions should the nurse give to the unlicensed assistive
personnel (UAP) who assisting with client’s care? (Select all that apply.)
A) Instruct the client about signs of orthostatic hypertension
B) Determine if the client needs to have a gait belt applied
C) Measure the clients vital signs before the
HESI RN FUNDAMENTALS TESTBANK Exam Questions and
Answers latest update 2022/2023
,HESI RN FUNDAMENTALS TESTBANK Exam Questions and
Answers latest update 2022/2023
client walks.
D) Offer to assist the client to void prior to
walking in the hall.
E) Report the onset of any dizziness or light headedness.
A z client zhas zbegun z a zlong-term z maintenance z therapy z with z lithium,
z which zhas za znarrow ztherapeutic zindex. zWhich zadverse zeffect zis zmost
important zfor znurse zto zinclude zin zthe zteaching zplan?
z
A) zDependence.
B) Toxicity.
C) Interaction.
D) Tolerance.
While z interviewing z a z client, z the z nurse z records z the z assessment z in z the
z electronic zhealth zrecord. zWhich zstatement zis zmost zaccurate zregarding zelectronic
documentationzduring zan zinterview?
z
A) The zinterview zprocess zis zenhanced zwith zelectronic zdocumentation zand zallows zthe zclient
to zspeak zat za znormal zpace.
z
B) Completing zthe zelectronic zrecord zduring zan zinterview zis za zlegal zobligation zof zthe
examining znurse.
z
C) The znurse zhas zlimited zability zto zobserve znonverbal
z communication zwhile zentering zthe zassessment
electronically.
z
D) zThe zclient’s zcomfort zlevel zis zincreased zwhen zthe znurse zbreaks zeye zcontact zto ztype
HESI RN FUNDAMENTALS TESTBANK Exam Questions and
Answers latest update 2022/2023
, HESI RN FUNDAMENTALS TESTBANK Exam Questions and
Answers latest update 2022/2023
notes zinto zthe zrecord.
z
A zclient zwho zlives zin zan zassisted zliving zfacility zdevelops zcognitive
impairmentzfollowing za zstroke. zInformed zconsent zis zneeded zto zprovide
z
additional znursing zservices. zWho zshould znurse zcontact?
z
A) The zclient’s zoldest zliving zchild, za zlawyer, zwho zis zvisiting zfrom zout zof ztown.
B) A zdaughter z-in-law zdesignated zas zthe zclient’s zDurable zPower zof zAttorney z(DPOA).
C) The zclient’s zyoungest zson, zidentified zby zfamily zmembers zas zthe zfamily zspokesperson.
D) The zclient’s zspouse zwho zlives zin zthe zindependent zliving zunit zof zthe zfacility.
A zclient zis zin zcontact zisolation zdue zto zstage zIV zcoccyx zwound zinfected zwith
z methicillin zresistant zstaphylococcus zaureus z(MRSA). zThe znurse zplans
interventionszto zprevent zmultiple zre-entries zto zthe zclient’s zroom. zIn zwhich zorder
z
should zthe znurse zperform zthe zinterventions?
z
A) Change zcoccyx zdressing, zperform ztracheostomy zcare, zrestart zthe zIV.
B) Perform ztracheostomy zcare, zchange zcoccyx zdressing, zrestart zthe zIV.
C) Restart zthe zIV, zperform ztracheotomy zcare, zchange zcoccyx zdressing.
D) zChange zcoccyx zdressing, zrestart zthe zIV, zperform ztracheostomy zcare.
What zself-care zoutcome zis zbest zfor zthe znurse zto zuse zin zevaluating za zclient’s
recoveryzform za zstroke zthat zresulted zin zleft- zsided zhemiparesis?
z
A) Promote zindependence zby zallowing zclient zto zperform zall zself-care zactivities.
B) Participates zin zself-care zto zoptimal zlevel zof zcapacity.
HESI RN FUNDAMENTALS TESTBANK Exam Questions and
Answers latest update 2022/2023