Evolve HESI Fundamentals
An older adult who is in acute care has a risk of skin breakdown. Which interventions are beneficial to the client? (Select all that apply) A. Providing meticulous skin care B. Reducing shear forces and friction C. Providing beverages and snacks frequently D. Using a support surface base all the time E. Avoiding pressure with proper positioning
A, B, E Providing an older adult with meticulous skin care may reduce the risk of skin breakdown. Reducing shear forces and friction prevents the development of pressure ulcers. Pressure can be avoided with proper positioning. Beverages and snacks are frequently provided to clients who are hospitalized due to dehydration. A supportive surface base is used based on risk factors.
Which condition in the client indicates need of nursing care that supports homeostatic regulation? (Select all that apply) A. Damaged Tissue B. Obstructed Airway C. Poor nutritional status D. Restricted body movement E. Altered patterns of urinary elimination
A, B Damaged tissue and an obstructed airway indicate that the client needs nursing care that supports homeostatic regulation [1] [2] Poor nutritional status, restricted body movement, and altered patterns of urinary elimination indicate that the client is in need of care that supports physical functioning.
While caring for a family, the nurse finds that the family has accepted the shifts of generational roles. Which change in the family status for proceeding developmentally would the nurse observe? A. Dealing with retirement B. Taking on parental roles C. Adjusting to a reduction in family size D. Refocusing on midlife material and career issues
A. A family with members in the later life stage may involve the acceptance of the shifting of generational roles. Therefore, dealing with retirement would be an appropriate change for the family status that requires a developmental proceeding. The acceptance of new generations of members into the system would be associated with the stage of a family with young children; this stage involves taking on parental roles. An adjustment to a reduction in family size would be associated with the family life cycle stage of launching children and moving on. Midlife material and career issues are refocused during the family life cycle stage of adolescence.
A nurse is caring for a client who is experiencing the second (acute) phase of burn recovery. The common client response the nurse expects to identify during this phase of burn recovery is an increase in what? A. Serum Sodium B. Urinary output C. Hematocrit Level D. Serum Potassium
B. As fluid returns to the vascular system, increased renal flow and diuresis occur. An increase in the serum sodium level (hypernatremia) is not a common response identified during the second (acute) phase of burn recovery. An increase in the hematocrit level indicates hemoconcentration and hypovolemia; in the second phase of burn recovery, hemodilution and hypervolemia occur. During the second phase of burn recovery, potassium moves back into the cells, decreasing serum potassium.
A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client? A. Evaluation B. Assessment C. Nursing interventions D. Proposed nursing care
B. An actual or potential client health problem is based on the analysis and interpretation of the data previously collected during the assessment phase of the nursing process. Gathering data is included in the client's assessment. Nursing interventions are based on the earlier steps of the nursing process. The plan of care includes nursing actions to meet client needs. The needs first must be identified before nursing actions are planned.
A client is receiving total parenteral nutrition (TPN) through a central venous access device. The nurse discovers that the TPN bag is empty and the next bag has not been received yet from the pharmacy. What is the most appropriate action for the nurse to take? A. Perform a fingerstick glucose test and notify the healthcare provider with the results B. Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for a new TPN bag C. Discontinue the infusion and flush the IV line with saline solution until the next TPN bag is ready D. Hang a bag of 5% dextrose at a keep-open rate and notify the nurse manager of the occurrence
B. Clients receiving TPN require monitoring of blood glucose because the TPN solution contains a high concentration of dextrose. In response to the high-dextrose TPN solution, the pancreas increases production of insulin to meet the glucose demands. In this situation, the current TPN infusion is completed, and the nurse should infuse 10% dextrose to compensate for the loss while the next TPN bag is being prepared. If this action is not taken, the client could experience a profound hypoglycemic reaction. After beginning an infusion of 10% dextrose, the nurse may perform a finger stick glucose test and notify the healthcare provider if the results are abnormal. Discontinuing the infusion and flushing the line until the next TPN bag is ready is not recommended. Starting an infusion of 5% dextrose at keep vein open (KVO) until the next TPN is ready may not prevent hypoglycemia; the nurse manager does not need to be involved unless there is a negative client outcome that results.
The Chief Operational Officer (COO) interviews a nurse and asks, "Tell me about your practical experiences in clinical decision making". Which example should the nurse give? A. I palpated the right hip of the client, which appeared red and noted the warm feeling B. I identified impaired skin integrity in a pressure ulcer form upon finding redness in the client's hip C. I quickly offered a salt recipe to a client with a history of hypotension who suffered from light-headedness and dizziness D. I assessed weakness and hunger in a patient with a history of diabetes who suffers with light-headedness and blurred vision
B. Clinical decision making is a problem-solving activity that focuses on defining a problem and selecting an appropriate action. So as a part of clinical decision making, the nurse identified impaired skin integrity in a pressure ulcer form upon finding redness in the client's hip. Diagnostic reasoning and inference is an analytical process that involves determining the client's health problems. An example is the nurse palpating and observing a warm sensation in the client's right hip that has turned red. Another example is a nurse who finds that a client who has hypotension history now feels light-headedness and dizziness. A further example is a nurse who assesses symptoms of diabetes in a client who has a history of the disease and now suffers blurred vision.
