Fundamental skills- HESI
Which description of family centered care is correct
A collaborative plan of care is developed to achieve optimal health
The nurse is explaining the nursing process to a student nurse which step of the nursing process would include interpretation of data collected about the client
Assessment
Which would the nurse recommend to help a client during the period immediately after a spouses death
Bereavement counseling
Which worker would the nurse consider to be at high risk of developing dermatitis
Dry cleaners dye workers
When caring for a client who is receiving enteral feedings the nurse would take which measure to prevent aspiration
Elevate the head of the bed between 30-45 degrees
The nurse should seek clarification by the practitioner for which order
Erythromycin 250 mg TIW
Which would the nurse consider to be the center of decision making when providing client care
Ethics
Which critical thinking skill refers to the use of knowledge and experience to choose effective strategies for client care
Explanation
Which statement is true about the nursing model of team nursing
Hierarchical communication exists from charge nurse to charge nurse, charge nurse to team lead, and team leader to team members
Which are extrinsic factors that determine motivation
Human resources community systems accessibility of facilities
A client who has received tap water enemas until clear is at risk for developing which complication
Hypokalemia
Which is an example of an independent nursing intervention
Keeping EDEMATOUS lower extremities elevated on pillows
The nurse would expect to find an increase of which substance in the urine of a client following a low carb diet
Ketones
Which is an indirect nursing care intervention
Managing the clients plan of care
The nurse provides crutch walking instructions to a client who has a left leg cast. Where would the nurse teach the client to place their weight
On the hands
Which concept refers to respecting the rights of others
Open mindedness
When monitoring a client 24-48 hours after abdominal surgery, the nurse would assess for which problem associated with anesthetic agents
Paralytic ileus
Which key factor would the nurse consider when assessing how a client will cope with body image changes
Perception of the change
The nurse tries several different ways to communicate with a client after thyroid surgery. Which critical thinking attitude is the nurse demonstrating
Perseverance
The nurse changed a dressing on a clients wound with VRE. Which step would the nurse take to ensure proper disposal of the soiled dressing
Place the dressing in a red bag hazardous materials bag
According to Kohlbergs development of moral reasoning, at which phase of life would a child develop a premoral orientation
Preschool
Which nurse collaborates with the client to establish and implement a basic plan of care of admission
Primary nurse
The nurse would primarily focus on which concept when providing pre operative teaching
Providing general info to reduce client and family anxiety
Which action of the nurse would be incorrect in the context of critical thinking skills for making clinical decision in nursing practice
Rely on knowledge and experience for client care
The nurse finds that a client prefers reiki to antidepressants for treating depression. Which intervention of the nurse indicates open mindedness
Respecting the clients preference
A client is likely to undergo reconstructive surgery for which purpose
Restore function and or appearance
A client who is in a late stage of pancreatic cancer intellectually understands the terminal nature of the illness. Which behavior indicate the client is emotionally accepting the impending death
Revising the client will and planning a visit to a friend
To prevent hemorrhage of a client who underwent a liver biopsy, the nurse would place the client in which position
Right side lying
How would the nurse prevent foot drop in a client with a leg dressing
Support the foot with 90 degrees of flexion
A terminally ill client is visited frequently by the spouse and teenage children. Which nursing interventions would the clients plan of care include
Teach family members how to assist with the clients basic care
Which statement defines the term family resiliency
The family has an ability to cope with stressors
Which example demonstrates humility in a critical thinker
The nurse accepts personal lack of knowledge regarding stem cell transplant and seeks opps for learning
While receiving a preop enema, a client starts to cry and says im sorry you have to do this messy thing for me. Which is the nurses best response
You seem upset
The nurse teaches a client about wearing thigh-high antiembolism elastic stockings. Which instruction would be correct to include
You will need to apply them in the morning before you lower your legs from the bed to the floor
The nurse would instruct a client with type 1 diabetes to dispose of a used syringe in which container
A plastic liquid detergent bottle with a screw top lid
Which of these is an ethical issue related to the long term care setting
ALL OF THEM (6)
The nurse realizes that a double dose of insulin was administered to the client by mistake and informs the PHCP. Which element of the decision making process is reflected int he nurses action
Accountability
After a below the knee amputation a client is refusing to eat talk or perform any rehab activities. Which approach would the nurse take when interacting with this client
Acknowledge that the clients withdrawal is an expected and necessary part of initial grieving
The nurse is caring for a client admitted with COPD. Which lab test would the nurse monitor for hypoxia
Arterial blood gas
Which behavior by the client exhibits denial after a recent diagnosis
Attempts to minimize the illness
Which is the rationale for the nurse informing the family what is going on with the client
Better equipped to undertake necessary family role changes
Which activity demonstrates fine motor skills in infants aged 2 to 4 months
Bringing objects from hand to mouth
The nurse would include which instruction to the parents of a child being treated with oral ampicillin for otitis media
Complete the entire course of antibiotic therapy
Which describes the purpose of preop antibiotics for a client scheduled for a surgical resection of the colon and creation of a colostomy
Decrease bacteria in the intestines
The nurse on the med surg unit tells other staff members, that client can just wait for the lorazepam. I get so annoyed when people drink too much. Which does this nurses comment reflect
Demonstration of a personal bias
The RN instructs a nursing student to use knowledge and experience to choose proper strategies when caring for clients. Which critical thinking skill would the RN be explaining
Explanation
The nurse is discussing discharge plans with a client. The client states, im worried about going home. The nurse responds tell me more about this. Which interviewing technique did the nurse use
Exploring
A client complains to the nurse manager about a coworker. The nurse manager listens to both the clients and the coworkers sides of the story. Which critical thinking quality is shown in this situation
Fairness
Which physiological changes are expected during the first trimester of pregnancy
Fatigue morning sickness breast Enlargement
Which principal components are associated with the nurses time management skills
Goal setting priority setting interruption control
A client who has had a MI is being discharged. The client asks the nurse when sexual activity can be resumed. Which response by the nurse is correct
Have you discussed this with your primary health care provider
The nurse is providing interventions to give support services for delivery of care. According to the NIC taxonomy, which domain does this care belong to
Health system
Which nursing process involves delegation and verbal discussion with the health care team
Implementation
Which intervention would prevent urinary stasis and formation of renal calculus in an immobile client
Increasing oral fluid intake to 2-3 L/day
The nurse is preparing to admin an oil retention enema and understands that it works primarily by which action
Lubricating the sigmoid colon and rectum
The nurse is assisting with the end of life care of a client. Which activity is performed when the nurse views family as a context
Meet the clients comfort, hygiene, and nutritional needs
A client has terminal cancer after 7 years of chemo and surgeries. The nurse enters the clients room and find them crying. Which is the correct intervention by the nurse
Sit down quietly next to the bed and allow the client to cry
The home health care nurse visits a client who lives with two grandchildren. Which term would the nurse use to define this family form
Skip generation family
Which definition is involved in the caring process called knowing, according to swan sons theory or caring
Striving to understand an event as it has meaning int he life of the other
Which nursing action reflects leiningers caring theory in practice
The nurse learns culturally specific behaviors to meet the clients needs
Which application in practice would best suit the critical thinking attitude of integrity
To be able to recognize personal opinions that may conflict with a clients opinion
Which feature is most likely related to entry level nurse competencies
Working and collaborating with other team members
A client is to receive a transfusion of PRBC. Which solution would the nurse use to prime the blood IV tubing
0.9% normal saline
Which consideration would the nurse make when obtaining an informed consent from a 17 year old
Determine whether the client is legally allowed to give consent
A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. Which is the correct therapeutic nursing interventions
Sitting quietly with the client
Which is the most important nursing action involved in caring for a client receiving medications
Admin the meds
The nurse is preparing an intraoperative care plan for a client. Which intervention would be excluded from the care plan
Administering a general anesthetic to the client
Which critical thinking skill will help a student nurse avoid making assumptions about clients
Analysis
When a client expresses anxiety about being given anesthesia, which team member should sit with the person and provide comfort during the induction
Circulating nurse
How can the nurse evaluate the effectiveness of communication with a client
Client feedback
The nurse tells the client who they are and explains a procedure to be performed. Which critical thinking attitude is the nurse applying
Confidence
Which change in family life cycle would the nurse advise the young couple planning to start a family to make
Consider relationships with extended family
A Spanish speaking client is being cared for by English speaking nursing staff. Which communication technique would be correct for the nurse to use when discussing health care decisions with the client
Contact an interpreter provided by the hospital
The nurse coworker approaches the nurse to inquire about the test results of a friend who is being cared for by the nurse. Which response by the nurse would be correct
Decline to discuss the friends medical condition
Which psychophysiological factors influence communication between the nurse and client
Emotional status growth and development
Which action would the nurse take to decrease abdominal distinction after a clients surgery
Encourage ambulation
The client has a visual impairment. Which technique would the nurse use to communicate
Encourage the client to use assistive devices such as eyeglasses
The nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. Which aspect of counseling would the nurse focus on
Evaluating whether the necessary lifestyle changes are understood
After being medicated for anxiety, the client says to the nurse i guess you are too busy to stay with me. Which response by the nurse is correct
I have to go now but i will come back in 10 minutes
The nurse is teaching a client about safe insulin admin. Which statement made by the client indicates the need for further education
I should admin insulin only if there are any symptoms
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
Which intervention would the nurse implement to develop a caring relationship with the clients family
Identifying the clients family members and their roles
A 58 year old client is planning to retire. Which assessment would be appropriate in this situation
Issues related to income
The nurse applies an ice pack to a clients leg for a total of 20 minutes. Which physiological effect would occur because of applying cold therapy
Local anesthesia
A client has been placing used insulin needles in a container sealed with heavy duty tape. Where would the nurse tell the client to dispose of the container
Local hazardous waste collection site
A client with cystic fibrosis asks why the percussion procedure is being performed. Which rationale would the nurse give to the client
Loosen pulmonary secretions
Two nurses are planning to help a client with one-sided weakness move up in bed. Which principle of body mechanics would the nurse observe
Position nurses on either side of bed with feet apart, gather the turn sheet close to the client, turn toward HOB, move the client
The plan of care for the client was to lose 7 lbs by the end of the month. The client lost only 3 lbs. which response by the he nurse is correct
Reevaluate the plan of care for appropriateness
Which nursing action would be considered a part of self-regulation in the decision making process
Reflecting on ones own experiences
A client with hemiplegia becomes frustrated when performing skills. Which nursing intervention would motivate the client towards independence
Reinforce success in tasks accomplished
Which caring intervention helps provide comfort, dignity, respect, and peace to a client
Relieving pain and suffering
Which right of delegation refers to the giving of clean, concise descriptions of a task to the delegate
Right communication
A client is on neutropenia precautions. From which direction does the protective environment isolation help prevent the spread of infection
To the client from outside sources
Which approach is a comforting approach that communicates concern and support
Touch
At which site would the nurse obtain a sterile urinalysis from a client with an in dwelling catheter
Tubing injection port
The new nurse is approached by a surveyor from the department of health. The surveyor asks the nurse about the best way to prevent the spread of infection. Which answer by the nurse is correct
Wash your hands
Which instruction is important for the nurse to include in discharge teaching for a client who has to perform intermittent urinary self cath
Wash your hands before performing the procedure
A client who wakes up after a surgery spits out the oral airway placed during the recovery from anesthesia. What does this behavior indicate to the nurse?
Gag reflex has returned
Which example in nursing practice would demonstrate watsons carative factor called forming a human altruistic value system
Using self disclosure to promote a therapeutic alliance with the client
The nurse is assessing a child who is accompanied by a parent and stepbrother. Which kind of a family does this child belong to
Blended
In which position would the nurse place the client to obtain an accurate reading of jugular vein distension
Raised to 30 degrees
Which nursing intervention would prevent septic shock in the hospitalized client
Use aseptic technique during all invasive procedures
Which fine motor skills may be observed in an 8 to 10 month old infant
Using pincer grasp well picking up small objects showing hand preference
The nurse is assessing a Latino Caribbean client who was brought to the hospital by family members. The family reports the client started crying shouting trembling and uncontrolled jerking of the extremities and then fell into a trance like state. Which condition would the nurse suspect
Ataque de nervios
Which guidance would the nurse educator provide to a graduate nurse who is seeking employment
Attend workshops and conferences work on developing effective communication consider institutions that provide mentoring
Which nursing intervention is performed for a middle aged client in tertiary care
Determining the coping mechanisms of the client and the family
An older adult is experiencing emotional stress after a recent surgery. Which intervention would be most appropriate for the client
Reality orientation
The nurse is developing a plan of care for the client who has activity intolerance. Which intervention would the nurse do to obtain the desired client outcomes
Set priorities and outcomes using the clients and family input
Which therapeutic communication technique is a coping strategy to help the nurse and client adjust to stress
Sharing humor
Which type of functional health pattern describes values and goals
Value belief pattern
WHICH IS THE FIRST SIGN THAT WOULD ASSIST THE NURSE IN SUSPECTING MALIGNANT HYPERTHERMIA IN A CLIETN
INCREASED EXPIRED CARBON DIOXIDE
The nurse is performing nursing care therapies and including the client as an active participant in the care. Which step int he nursing process is involved in this situation
Implementation
Which would the nurse teach the parents of an infant about the use of car seats
Infants should be restrained properly in a federally approved car seat safety seat
Which nursing intervention is classified under complex phsyiological domain according to the NIC taxonomy
Interventions to restore tissue integrity interventions to optimize neurological functions interventions to provide care before during and immediately after surgery
Which standard is important for the nurse to use in critical thinking
Specific relevant
During the beginning phase of a therapeutic relationship why is a clear understanding of participating role important
To know what to expect from the relationship
Which is an example of independent thinking in nursing practice
Talking with other nurses to share ideas about nursing interventions
Which nurse is using complex critical thinking skills when caring for a client
Talks to the client to identify reasons for their behavior
The nurse is caring for a postop client who had general anesthesia. Which independent nursing intervention would prevent an cumulative of secretions
Frequent changes of position
Which percentage do health behaviors such as physical activity and diet contribute to health outcomes according to the CHR model
30%
Which therapeutic communication technique is used when the nurse and a client have a conversation and the client begins to repeat the conversation to self
Focusing
Which principle would be considered when caring for a client with a closed wound drainage system
Fluids flow from an area of higher pressure to one of lower pressure
Which carative factor of watsons trans personal caring theory is reflected when the nurse practices loving kindness
Forming a human altruistic value system
Which caring process is defined as facilitating the others passage through life transitions and unfamiliar events according to swan sons theory of caring
Enabling
Which action indicates that the nurse is actively listening to the client
Interpreting what the client is saying and restating it for clarification
The nurse develops a goal that makes a client feel as if the client is engaging in a competition. Which type of motivation is the nurse using in this situation
Power motivation
Which carative factor is involved in creating a healing environment at all levels, physical and non physical, according to watsons theory of trans personal caring
Providing for a supportive, protective, and or spiritual environment
Which stage of kohlbergs theory of moral development reflects children follow the parents rule of being at home on time
Stage 2
The nurse is providing restraint education to a group of nursing students. Which reason to use restraints is INCORRECT to teach
To prevent an adult client from getting up at night when there is insufficient staffing on the unit