hesi case 1 (fundamental skills)

Which professional standard does the nurse feel is most important for critical thinking?

Evaluation criteria An evaluation criterion is an important professional standard required for critical thinking. Logical thinking, accurate knowledge, and relevant information are important intellectual standards required for critical thinking.

Family of context? The nurse is assisting with the end-of-life care of an older adult. Which activity is performed when the nurse views family as context?

Meet the client's comfort, hygiene and nutritional needs When viewing family as context, the nurse mainly focuses on the client's comfort, hygiene, and nutritional needs. Family as context means focusing on the health and development of a client. "focus on the individual patient"

A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client does what?

Moves the walker no more than 12 inches (30.5 cm) in front of the client during use

A nurse provides crutch-walking instructions to a client who has a left-leg cast. The nurse should explain that weight must be placed where?

On the hands Body weight should be placed on the hands. NOT under the arms in the axillae when a client is walking with crutches to prevent damage to the brachial plexus nerves and prevent "crutch paralysis." Placing weight in the axillae during crutch walking is incorrect. Weight during walking with two crutches should be distributed equally to both sides of the body without regard to the unaffected side or either side or the side the client prefers.

What type of functional health pattern would the nurse explain describes values and goals?

Value-belief pattern Value-belief pattern describes a pattern of values, beliefs, and goals. These guide the client for making choices or decisions.

5 rights of delegation

right... - task - circumstance - person - communication - supervision

The family of an older adult who is aphasic reports to the nurse manager that the primary nurse failed to obtain a signed consent before inserting an indwelling catheter to measure hourly output. What should the nurse manager consider before responding?

A separate signed informed consent for routine treatments is unnecessary. This is considered a routine procedure to meet basic physiologic needs and is covered by a consent signed at the time of admission. The need for consent is not negated because the procedure is beneficial. This treatment does not require special consent.

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia?

Arterial blood gas. Red blood cell count, sputum culture, and total hemoglobin tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status.

The nurse is helping a client and his or her family to set and meet goals with minimal financial cost, time, and energy. Which professional role of the nurse is applicable in this situation?

Caregiver As a caregiver, the nurse helps the client and his or her family set goals. The nurse also assists them in meeting these goals with a minimal financial cost, time, and energy.

When performing a postoperative assessment, which parameter would alert the nurse to a common side effect of epidural anesthesia?

Decreased blood pressure The most important side effect to monitor in a client who has received epidural anesthesia is HYPOTENSION d/t autonomic nervous system blockade. Therefore, in the immediate postoperative recovery period, the blood pressure should be assessed frequently. Other side effects include bradycardia, nausea, and vomiting. Increased oral temperature and unequal bilateral breath sounds are not effects associated with epidural anesthesia. Diminished peripheral pulses may result from hypotension, although they are not the most common side effects.

nurse as a manager

In the manager role, the nurse coordinates the activities of members of the nursing staff and has personnel, policy, and budgetary responsibility for a specific nursing unit or agency.

sharing empathy

Sharing empathy is the ability to understand and accept another person's reality, accurately perceive feelings, and communicate this understanding to the other.

Which therapeutic communication technique involves using a coping strategy to help the nurse and client adjust to stress?

Sharing humor is a therapeutic communication technique that involves using a coping strategy that adds perspective and helps the nurse and client adjust to stress.

nurse as a advocate

The advocator role helps protect the client's human and legal rights and provide assistance in asserting these rights if the need arises.

What should the nurse include in dietary teaching for a client with a colostomy?

The diet should be adjusted to include foods that result in manageable stools. Each person will need to experiment with diet after a colostomy to determine what foods are best tolerated and produce stools that are manageable depending on the type of colostomy. Liquids are typically not limited unless there is a specific reason such as cardiac or renal disease. Foods high in fiber such as fruit should be included in the diet as tolerated. Depending on the type of colostomy and the diet, a formed stool is acceptable and does not indicate a constipating diet.

nurse as a educator

The educator role is used to explain concepts and facts about health, describe the reason for routine care activities, demonstrate procedures such as self-care activities, reinforce learning or client behavior, and evaluate the client's progress in learning.

role-relationship pattern

The role-relationship pattern includes the description of the client's patterns in role engagements and relationships.

sharing hope

Nurses should recognize that hope is essential for healing and communicate a sense of possibility.

Which HEALTHCARE factors create barriers that prevent older adults from participating in healthcare promotion and disease prevention? Select all that apply.

Personal motivation + Previous healthcare experience Personal motivation and previous healthcare experience are factors that create barriers that prevent older adults from participating in healthcare promotion and disease prevention. Finances, activity levels, and transportation are barriers, but are NON-health factors.

A nurse is caring for a client with hemiplegia who becomes frustrated when performing skills. How can the nurse motivate the client toward independence?

Reinforce success in tasks accomplished. Success is a basic motivation for learning. People receive satisfaction when a goal is reached. Progress toward long-range goals often is not apparent readily and may be discouraging. Constructive criticism is an important aspect of client teaching, but if it is not tempered with praise, it is discouraging. Demonstrating ways to promote self-reliance is an important part of teaching, but it probably will not motivate the client.

After being medicated for anxiety, a client says to a nurse, "I guess you are too busy to stay with me." How should the nurse respond?

"I have to go now, but I will come back in 10 minutes." --> answers the client's question The response "I have to go now, but I will come back in 10 minutes" demonstrates that the nurse cares about the client and will have time for the client's special emotional needs. This approach allays anxiety and reduces emotional stress. Saying "I'm so sorry, but I need to see other clients" indicates that the nurse's other tasks are more important than the client's needs. Telling the client "you'll be able to rest after the medicine starts working" is false reassurance and not therapeutic. Saying "you'll feel better after I've made you more comfortable" does not respond to the client's need and cuts off communication.

A hospitalized client is scheduled to have a sigmoidoscopy. The nurse anticipates that preprocedure prescriptions will include what?

Administering a Fleet enema 1 hour before the procedure To facilitate visualization of the rectum and the sigmoid colon, the lower colon must be emptied immediately before the procedure. A Fleet or tap water enema should be used. Restraints are not typically used during the procedure. The client will be kept nothing by mouth (NPO) for at least 8 hours before the procedure. Morphine is not typically used as a preoperative medication before a sigmoidoscopy.

Health perception-health management pattern

Health perception-health management pattern is associated with the description of the client's self report of health and well-being.

Right person

Right person is delegating a task to the correct person who has the ability to perform said task.

The home healthcare nurse visits a client who lives with her two grandchildren. The client's daughter is a single-parent who is away at work and comes home only on weekends. Which term does the nurse use to define this family form?

Skip-generation family A skip-generation family form is a kind of alternative family form where the grandparents care for the grandchildren. Divorce, working parents, and single parenthood are some of the reasons that lead to such family forms. A nuclear family consists of a husband and wife and one or more children. An extended family consists of the nuclear family and relatives such as aunts, uncles, cousins, or grandparents. A single-parent family is formed when one parent leaves the household due to death, divorce, or desertion. It may also occur when a single person decides to have or adopt a child.

The registered nurse is teaching a nursing student about caring for a client who has difficulty speaking English. Which statement made by the nursing student would cause communication problems with the client? 1 "I will give the client a call bell." 2 "I will involve the client's family members as interpreters." 3 "I will provide a dictionary to the client if the client can read." 4 "I will use boards and pictures to communication with the client."

2 "I will involve the client's family members as interpreters." would cause problems The nurse should not involve the client's family, especially children, as interpreters because they may misinterpret the client's feelings. The nurse should provide a call bell to the client to help the client ask for assistance. The nurse should provide a dictionary to the client if the client can read to help the client to easily interpret his or her feelings. The nurse should use communication boards and pictures aid in clear and effective communication with a client. number 1, 3, 4 would not cause problems

The registered nurse is teaching a nursing student about nursing care principles for cognitively impaired older adults. Which statement made by the nursing student indicates a need for further education?

"I should provide conditional positive support." wrong, indicates further teaching need the student nurse can encourage fluid intake, promote social interaction based on abilities, and provide ongoing assistance to family caregivers When caring for cognitively impaired older adult, the nurse should provide UNCONDITIONAL POSITIVE SUPPORT and respect. The nurse should encourage the client to drink fluids. The nurse should promote social interactions based on abilities. The nurse should provide ongoing assistance to family caregivers, educate them in nursing care techniques, and inform them about community resources.

A home health nurse on a first visit checks the client's vital signs and obtains a blood sample for an international normalized ratio (INR). After these tasks are completed, the client asks the nurse to straighten the blankets on the bed. What is the nurse's most appropriate response?

"Of course. I want to do whatever I can for you." Helping the client to meet physical needs is within the role of the nurse; arranging blankets on the client's bed is an appropriate intervention. The nurse's comfort needs should not take precedence over the client's needs; the nurse should not assume responsibility for the role of care provider if incapable of providing care. This act is not a good deed but fulfills the expected role of the nurse; this response sounds grudgingly compliant. This is within the nurse's job description.

The nurse is caring for a client who had a hip replacement 2 days prior. After removing a bedpan from under the client, what is a priority nursing intervention?

Provide perineal care. Providing perineal care helps to preserve skin integrity for the client who is incapable of providing self-care. Turning and positioning the client who has decreased physical mobility after hip surgery is important in preventing skin breakdown, but it is not an immediate client need. Giving a complete bed bath is not necessary after each bowel movement because only the perineal area is typically soiled. Documenting the bowel movement should be done only after meeting immediate needs of the client.

What does the nurse recognize as the reason the faucet handles on the sinks in a client's room are considered contaminated?

They are touched by dirty hands when turning the water on. --> hand hygiene Unwashed hands are considered contaminated and are used to turn on sink faucets. Recontamination of washed hands may be prevented by using foot pedals or a paper towel barrier when closing the faucets. They are not considered contaminated because they are not in sterile areas; areas cannot be sterile. It is unrelated to the number of people, but rather to being touched by contaminated hands. Although bacterial growth is facilitated in moist environments, this is not why sink faucets are considered contaminated.

family as a client

When viewing family as a client, the client's family comfort and nutritional needs are focused on, and the nurse determines the family's needs for rest and their stage of coping. "focus on the family"

The nurse is assessing a client with arthritis. Which statement made by the client indicates a precipitating factor that is an intellectual standard for critical thinking?

"I run for 30 minutes every day; this exercise increases my pain." A precipitating factor is an activity or factor that worsens the symptoms. If running for 30 minutes each day increases the client's pain, this action is a precipitating factor. By saying, "The pain is usually present in my fingers and knees," the client is providing information about the location. Swelling and redness are concomitant symptoms of pain. The quality factor indicates the description of the symptom; this is exemplified by the statement, "I feel the pain in each and every joint of my hands and legs."

Which workers would the nurse consider to be at high risk of developing dermatitis? Select all that apply.

dry cleaners + dye workers Dry cleaners and dye workers are at high risk of developing dermatitis due to exposure to substances such as solvents and dye stuffs. Lathe operators are at high risk of developing cancer. Hospital workers are at greater risk of latex allergies. Agricultural workers are at high risk of skin cancer.

A nurse provides discharge teaching related to intermittent urinary self-catheterization to a client with a new spinal cord injury. Which instruction is most important for the nurse to include?

"Wash your hands before performing the procedure." To prevent transferring organisms to the urinary system, the client is taught to wash his or her hands thoroughly with soap and water before inserting a clean catheter. Sterile gloves are not required for this procedure in the home care setting. Every 12 hours is too long of a time frame between catheterizations. The client should be taught to recognize when self-catheterization is needed and develop a 2- to 3-hour catheterization schedule. Some home care settings may require the client to clean and re-use catheters.

An advanced practice registered nurse (APRN) is caring for a pregnant woman. Which type of APRN would care for this client?

A certified nurse midwife (CNM) is qualified and has the skills to care for a pregnant woman. A clinical nurse specialist (CNS) is an advanced practice registered nurse (APRN) who is an expert clinician in a specialized area of practice. A certified nurse practitioner (CNP) is an APRN who provides healthcare to a group of clients, usually in an outpatient, ambulatory care, or community-based setting. A certified registered nurse anesthetist (CRNA) is an APRN with an advanced education in a nurse anesthesia accredited program.

A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by doing what?

Causing local vasoconstriction, preventing edema and muscle spasms Cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues and prevents swelling and therefore muscle spasms. Cold does promote analgesia but not circulation. It may numb nerves but does not dilate blood vessels. Cold therapy also may numb the nerves and surrounding tissues, thus reducing pain.

What safety factor should the nurse teach parents about using a crib for an infant?

Check the slats are less than 6 cm (2.4 in) apart. If parents are using an older crib, they should check that the slats are less than 6 cm (2.4 in) apart. The federal safety standard has prohibited the manufacture of cribs with drop-side rails. Parents should avoid using soft mattresses, toys, or pillows inside the crib to reduce the risk for sudden infant death syndrome (SIDS). Toys with hanging strings can lead to accidents. Toys should be attached firmly without any hanging strings.

While measuring the rectal temperature, the nurse inserts the thermometer probe 2.5 to 3.5 cm into the anus in the direction of the umbilicus. What would be the rationale behind this?

Ensure adequate exposure to the blood vessels The nurse should place the thermometer probe into the anus in the direction of umbilicus to ensure adequate exposure to the blood vessels. Wiping the client's anal area with a soft tissue and helping the client get into the Sims' position provides comfort. Using a lubricant will help to minimize trauma to the rectal mucosa. The nurse should wash his or her hands before and after assessing the temperature to reduce the transmission of microorganisms.

fairness humility discipline

Fairness requires the nurse to listen to both the sides in any discussion. Humility is associated with recognizing the need for more information for making a decision. When the nurse is thoroughly aware of what is required and manages his or her time effectively, he or she uses discipline.

self-perception-self-concept pattern

In the self-perception-self-concept pattern, the nurse may describe the client's self-concept pattern and perceptions of self. It involves self-concept/worth, emotional patterns, and body image.

Which action of the nurse would be most important to convey interest in starting a conversation with a client who has hearing loss?

Making eye contact with the client The nurse should make eye contact with the client to show interest in starting a conversation with a client with hearing loss. Smiling while seeing the client would help to build a positive relationship. Nodding in front of the client helps to regulate the conversation. Leaning forward towards the client shows attention and awareness.

A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has vancomycin-resistant enterococci (VRE). After notifying the healthcare provider, which action should the nurse take to decrease the risk of transmission to others?

Move the client to a private room. --> CONTACT precaution Contact precautions are used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment; therefore infectious clients must be placed in a private room. There is no need to insert an indwelling catheter as this can increase the risk for additional infection. Droplet precautions are used for clients known or suspected to have infections transmitted by the droplet route. These infections are caused by organisms in droplets that may travel 3 feet but are not suspended for long periods.

When monitoring a client 24 to 48 hours after surgery, the nurse should assess for which problem associated with anesthetic agents?

Paralytic ileus colitis, stomatitis are poth inflammation d/t infection After surgery clients are at risk for paralytic ileus as a result of receiving an anesthetic agent. The nurse can prevent or minimize paralytic ileus by increasing movement as soon as possible after surgery, through actions such as turning and early ambulation. Evidence of bowel function returning to normal includes auscultation of bowel sounds and passing of flatus and stool. Colitis, stomatitis, and gastrocolic reflux are not postoperative complications related to anesthetic agents.

The nurse receives information about a client through another nurse. The nurse then finds that information has some missing facts. Which critical thinking attitude would the nurse use to clarify the information after talking to the client directly?

Perseverance Perseverance requires the nurse to be cautious of an easy answer. If the nurse clarifies some information after talking to the client directly, he or she demonstrates perseverance.

Right supervision

Right supervision refers to providing appropriate monitoring, evaluation, and feedback of the delegated task.

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.

Providing meticulous skin care Reducing shear forces and friction Avoiding pressure with proper positioning support surface base, NOT all the time but based on risk factors 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.

Right task

Right task refers to delegating a task that is repetitive, requires less supervision, and has predictable results.

The nursing team is providing care for a client. The team leader develops client care plans and coordinates care among the team members. Which member of the team acts as a team leader?

Registered nurse The registered nurse acts as a team member by creating a care plan for the client and coordinating the care among the team members. The registered nurse works directly with the client, family, and healthcare team members. The charge nurse assigns tasks to the other healthcare professionals if the registered nurse is absent. The licensed practical nurse provides care to the client under the supervision of registered nurse. The UAP are team members who provide care to the client under the supervision of the registered nurse.

Which right of delegation refers to the giving of clear, concise descriptions of a task to the delegatee?

Right communication refers to the giving of clear and concise descriptions of a task, including its objectives, limits, and expectations while delegating a task.

sharing observations

Sharing observations often helps a client to communicate without the need for extensive questioning, focusing, or clarification.

family as a system

When viewing family as a system, the nurse mainly focuses on assessing the resources available to the family. Family as system includes both family as context and family as a client. "focus on individual + family at the same time"