HESI FUNDS

The nurse has provided instructions about back safety to a client. Which statement by the client indicates understanding of these instructions?

"I will carry objects close to my body" By carrying objects close to the center of the body, the client can lessen back strain. Sleeping on the stomach, pulling objects, and carrying objects too far away from the body add pressure and strain to the back muscles.

The nurse encounter resistance when inserting the tubing into a client's rectum for a tap water enema. What action should the nurse implement?

Ask the client to relax and run a small amount of fluid into the rectum. If resistance is encountered during the initial insertion of an enema tube, the client should be instructed to relax while a small amount of solution runs through the tube into the rectum

Which theory describes the phenomenon of grief or caring?

Descriptive theories Descriptive theories describe a phenomenon such as grief or caring. Grand theories provide the structural framework for broad, abstract ideas about nursing. Prescriptive theories discuss interventions and expected outcomes for a specific phenomenon. They describe phenomena, speculate on why they occur, and describe their consequences. Middle-range theories have a more narrow scope than grand theories; these theories integrate theory-based research with nursing practices.

Which factor would the nurse assess in a client reporting constipation?

Diet, Fluid Intake, Laxative Use, Date of Last Bowel movement, Use of opioid pain medications

Which of these cultural groups adopts a combination of dietary, herbal, and other naturalistic therapies to prevent and treat illness?

Asian Indians Asian Indians rely on a combination of dietary, herbal, and other naturalistic therapies to prevent and treat illness. East Asians use yin treatment (which uses needles to restore balance and flow of qi) and yang treatment (which uses moxibustion or heat with acupuncture to restore the yin/yang balance). Hispanics use a combination of prayers, herbs, and other rituals to treat traditional illnesses. Native Americans rely on a combination of prayers, chanting, and herbs to treat illnesses caused by supernatural, psychological, and physical factors.

A signed consent form indicated a client should have an electromyogram, but a myelogram. was performed. instead. Though the myelogram revealed the cause of the client's back pain, which w as subsequently treated, the client filed a lawsuit against the nurse and healthcare provider for performing the incorrect procedure. The court is likely to rule in favor of the plaintiff because these events represent what infraction?

Assault and battery with deliberate intent to deviate from the consent form. The client was not properly informed of the procedure, and failure to obtain informed consent constitutes assault and battery (C). (A) is injury to economics and dignity, such as invasion of privacy or defamation of character. This is not an incident of failure to respect the client's autonomy (B). An unintentional tort (D) is an act in which the outcome was not expected, such as negligence or malpractice.

Which intellectual factor would the nurse consider as a dimension when gathering data for a client's health history?

Attention span Attention span is an intellectual dimension used to gather data for a health history. The social dimension for gathering the health history includes primary language. A coping mechanism is considered to be a social subdimension used to gather a client's health history data. Physical and developmental subdimensions would include activities and coordination.

The nurse who promotes freedom of choice for clients in decision- making best supports which principle?

Autonomy The principle of autonomy relates to the freedom of a person to form her or his own judgments and actions. The nurse promotes autonomy so as not to infringe on the decisions or actions of others. Justice means to be righteous, to be equitable, and to act or treat others fairly. Beneficence relates to the state or act of doing good and being kind and charitable. It also includes promotion of well-being and abstaining from injuring others. Paternalism encompasses the practice of governing people in a fatherly manner, especially by providing for their needs, without infringing on their rights or responsibilities.

When assessing a patient for malnutrition, the nurse would monitor for an increase in liver enzymes and a decrease in which water-soluble vitamin?

Biotin, Niacin, Folic Acid, Riboflavin, Vitamin C Water-soluble vitamins include biotin, niacin, folic acid, riboflavin, vitamin C, thiamine, pyridoxine, cyanocobalamin, and pantothenic acid. These along with fat- soluble vitamins are decreased during malnutrition along with elevated liver enzymes.

What intervention should the nurse include in the plan of care for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency?

Check capillary refill of toes on lower extremity with Unna's paste boot Boot becomes rigid after it dries, so it is important to check distally for adequate circulation. No bandage should be put under it. Should be applied from foot & wrapped towards knee. Acts as a sterile dressing & should not be removed q8h. Weekly removal is reasonable.

Which domain of the nursing intervention phase includes electrolyte and acid-base management?

Domain 2 Domain 2 of the nursing intervention phase includes electrolyte and acid-base management. Domain 2, or the physiological complex, includes care that supports homeostatic regulation. Domain 1 includes care that supports physical functioning. Domain 3 incorporates care that supports psychosocial functioning and facilitates lifestyle changes. Domain 4 involves care that supports protection against harm.

The nurse is caring for a client who is having diarrhea. Which client data would the nurse closely monitor to prevent an adverse outcome?

Fluid and electrolyte balance Monitoring fluid and electrolyte balance is the most important nursing intervention because excess loss of fluid through the multiple loose bowel movements associated with diarrhea lead to alteration in fluid and electrolyte imbalance. Although skin may become excoriated with diarrhea, this is not a life-threatening condition and is not the nursing priority. Even though absorption of nutrients is decreased with diarrhea malnutrition, it is not a life-threatening condition and is not the priority nursing intervention. Fluid intake and output provides information about fluid balance only, without taking into consideration the loss of electrolytes that accompanies diarrhea and is not the best choice.

A client is discussing with the nurse concerns about their unhealthy family relationships. During the nurse-client interaction the client begins to talk also about a job problem. The nurse's response is, 'Let's go back to what we were just talking about.' Which therapeutic communication technique did the nurse use?

Focusing Focusing is a technique that directs a client back to the original topic of discussion. Restating the main idea of what the client has said encourages the client to continue speaking or clarifies what has been said. Exploring permits the nurse to delve deeper into the subject when the client tends to stay on a superficial level. Accepting is a technique used to understand and demonstrate regard for what the client stated.

The nurse is assigned to change a central line dressing. The agency policy is to clean the site with povidone-iodine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede povidone-iodine in a dressing change. In addition, an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and povidone- iodine. The nurse has a sample of the new product. How would the nurse proceed?

Follow the agency's policy unless it is contradicted by a primary health care provider's prescription. Agency policy determines procedures; if the procedure is out of date or problematic, the nurse would contact the primary health care provider for a change in the prescription. The nurse cannot use another product without a primary health care provider's prescription. The nurse will be risking liability if agency policy is not followed, unless the prescription is changed by the primary health care provider

A client tells the nursing assistant 'I am so worried about the results of the biopsy they took today.' The nurse overhears the nursing assistant reply, 'Don't worry. I'm sure everything will come out all right.' Which conclusion would the nurse make about the nursing assistant's answer?

Gives false reassurance

Which physical change would the nurse observe in a client with malnutrition?

Hypotension, dry dull hair, abdominal edema (seen with protein malnutrition), delayed wound healing, and depletion of muscle mass all are signs of malnutrition.

A healthcare provider is performing a sterile procedure at a client's bedside. Near the end of the procedure, the nurse observes the healthcare provider contaminate a sterile glove and the sterile field. What is the best action for the nurse to implement?

Identify the break in surgical asepsis and provide another set of sterile supplies. Any possible break in surgical asepsis that is identified when others are unaware should be considered contaminated and new sterile supplies added to maintain the sterile field (D). Reporting the healthcare provider is not indicated (A). When sterility is suspect during aseptic technique, it should not be questioned (C) but all members of the team should move forward with reestablishing a sterile field. Allowing the procedure to progress under unsterile conditions (B) places the client at risk for infection and is an act of omission (negligence) by the nurse and other healthcare team members.

Which clinical finding would the nurse associate with hypokalemia?

Muscle weakness. Serum hypokalemia diminishes the magnitude of the neuronal and muscle cell resting potentials. This can result in observable muscle weakness. Edema is associated with electrolyte imbalances, including sodium excess (hypernatremia). Muscle spasms and twitching are often seen in the setting of hypocalcemia. Kussmaul respiration is a breathing pattern characterized by deep and labored breaths in response to metabolic acidosis, especially diabetic ketoacidosis.

Which food would the nurse recommend to a client when instructing to increase potassium intake?

Oranges and other citrus fruits Oranges and other citrus fruits contain potassium. Onions, celery, cheese, and oatmeal do not contain potassium in any significant amounts.

The nurse assesses for hypocalcemia in a post operative client. Which is one of the initial signs that might be present?

Paresthesias Normally, calcium ions. block the movement. of sodium into cells. When calcium is low, this allows sodium to move freely into cells, creating increase excitability of the nervous system. Initial symptoms are paresthesias. This can lead to tetany if untreated. Headache, pallor, and blurred vision are not signs of hypocalcemia.

A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from the 24-hour dietary recall? (Select all that apply.)

Potato chips (A) are high in sodium. Tuna (B) is high in protein. Bacon (C) and crackers (E) are high in sodium. Only (D) is a meal that is in compliance with a low sodium, low protein die

Which nurse collaborates with the client to establish and implement a basic plan of care on admission?

Primary Nurse The primary nurse provides or oversees all aspects of care, including assessment, implementation, and evaluation of that care. A clinician is an expert teacher or health care provider in the clinical area. The nurse coordinator oversees all the staff and clients on a unit and coordinates care. Clinical nurse specialist is a title given to the nurse specially prepared for one very specific clinical role. It requires a master's degree level of education.

Which position is indicated to assess the musculoskeletal system but is contraindicated in clients with respiratory difficulties?

Prone Prone position is indicated to assess the musculoskeletal system in clients, but it is indicated with caution in clients with respiratory difficulties because they cannot tolerate this position well. Left lateral recumbent position is indicated to assess the rectum and vagina. Supine position is indicated for general examination of head and neck, anterior thorax, breast, axilla, and pulses. Knee-chest position is indicated for rectal assessment.

On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination?

Provide warm prune juice before the client goes to bed at night. Prune juice is a natural laxative that stimulates peristalsis, and warming the prune juice (B) facilitates peristalsis. (A) is also helpful in promoting peristalsis but is less likely to relieve the client's constipation. (C) reduces discomfort during ambulation, but will not help relieve the client's constipation. Defecation is not painful following most surgeries, and many analgesics used postoperatively cause constipation, so (D) is contraindicated.

A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for nurse to obtain?

Sensory pattern, area, intensity, and nature of the pain. The components of every pain assessment should include sensory patterns, area, intensity, and nature (PAIN) of the pain (A) and are essential in identifying appropriate therapy for the client's specific type and severity of pain, which may indicate the onset of disease progression or complications. Triggers (B), current drug usage (C), and sympathetic responses (D), such as tachycardia, diaphoresis, and elevated blood pressure, are important, but should be obtained after focusing on (A).

Which theory provides a basis for identifying and testing nursing care behaviors to determine if caring improves client health outcomes?

Swanson's Theory of Caring Swanson's theory of caring provides a basis for identifying and testing nursing care behaviors to determine if caring improves client health outcomes. Neuman's system theory focuses on stressors perceived by the client or caregiver. Orem's self-care deficit theory explains the factors within a client's living situation that support or interfere with his or her self-care ability. Mishel's theory of uncertainty in illness focuses on a client's experiences with cancer while living with continual uncertainty.

A single mother of two teenagers, ages 16 and 18, was just told that she has advanced cancer. She is devastated by the news, and expresses her concern about who will care for her children. Which statement by the nurse is likely to be most helpful at this time?

Tell me what you would like to see happen with your children in the future. The nurse should first assess what the client desires (C). (A) is somewhat judgmental and attempts to solve the problem for the client without eliciting the client's feelings. Though a referral to the social worker (B) may be indicated, the nurse should first offer support. Time is likely to help the client cope with this news (D), but the nurse should first provide support and assess what the client wants to see happen with her children.

Which definition of battery would the nurse include when teaching staff about legal terminology used in child abuse?

The application of force to another person without lawful justification. Battery means touching in an offensive manner or actually injuring another person. Battery refers to actual bodily harm rather than threats of physical or psychological harm. Battery refers to harm against persons, not property. Behaving in a way that a reasonable person with the same education would not is the definition of negligence.

The nurse creates a plan of care for a client with a risk of infection. Which is the desirable expected outcome for the client?

The client will be free of signs and symptoms of infection by discharge. Whenever a client has an infection or is at risk for infection, the nurse's primary objective in providing care is to prevent infection or perform activities that will promote the client's being free from infection by the time of discharge. The other expected outcomes are desirable but are more general in nature.

Which statement is true about prescriptive theories?

They are action-oriented Prescriptive theories are action-oriented. They test the validity and predictability of a nursing intervention. These theories address nursing interventions for a phenomenon, describe. the conditions under which. the prescription occurs and predict the consequences. Descriptive theories help explain client assessment. A middle-range theory tends to focus on a specific field of nursing. Descriptive theories are the first level of theory development.

The client is on neutropenic precautions. From which direction does the protective environment isolation help prevent the spread of infection?

To the client from outside resources. Protective environment isolation implies that the activities and actions of the nurse will protect the client from infectious agents because the client's own immune defense ability is compromised ( neutropenia). Protective environment isolation is also referred to as reverse isolation. 'From the client to others,' 'From the client by using special techniques to destroy infectious fluids and secretions,' and 'To the client by using special sterilization techniques for linens and personal items' are incorrect concepts related to protective environment isolation.

Which would the nurse understand by the quality improvement competency, according to Quality and Safety Education for Nurses (QSEN)?

Using data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems The quality improvement competency states that the nurse would use data to monitor the outcomes of health care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems. According to the competency called informatics, the nurse would use information and technology to communicate, manage knowledge, mitigate errors, and support decision-making. As per the competency called evidence-based practice, the nurse would integrate best current evidence with clinical expertise and client and family preferences and values for the delivery of quality health care. According to the competency called teamwork and collaboration, the nurse would function effectively within nursing and interprofessional teams by fostering open communication, mutual respect, and shared decision-making to achieve quality client care.