Fundamentals Assessment Intro to AH HESI

The nurse removes the dressing on a client's heel that is covering a pressure sore

One-inch pressure sore draining serous fluid

An older client who is able to stand but not to ambulate receives a prescription

Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed

How should the nurse handle linens that are soiled

Place the soiled linens in a pillow case and deposit them in the dirty linen hamper

What action should the nurse implement to prevent the formation of a sacral ulcer

Position prone with a small pillow below the diaphragm

On the third postoperative day following thoracic surgery

Provide warm prune juice before the client goes to bed at night

The nurse is digitally removing a fecal impaction for a client

Pulse rate decreases from 78 to 52 beats/min

What action is most important for the nurse to implement when placing a client in the Sim's position

Raise the bed to a waist-high working level

A home health nurse visits an elderly female client who had a brain attack three months ago

The nurse notes that there are numerous scatter rugs throughout the house

A medication is prescribed to be given QID

0800, 1200, 1600, 2000

A nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate

1) Ask the client to push the IV pole to the chair 2) Pre-medicate client with an analgesic 3)Inform the client of the plan for moving to the chair 4) Assess the client's blood pressure

A low-sodium, low-protein diet is prescribed for a 45-year-old client

1) Bedtime snack of crackers and milk 2)Breakfast of eggs, bacon, toast, and coffee 3) Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee 4) Snack of potato chips, and diet soda

The nurse working in the emergency department is assessing four clients' ability to tolerate pain

A 55-year-old woman who has had moderate low back pain for three months

Which technique is most important for the nurse to implement when performing a physical assessment

A consistent, systematic approach

A female nurse who sometimes tries to save time by putting medications in her uniform pocket

Accused of diversion

The nurse is caring for a client who is weak from inactivity because of a 2-week hospitalization

Active ROM exercises to both arms and legs two or three times a day

Prior to administering a newly prescribed medication to a client

Analysis

What is the rationale for using the nursing process

As a tool to organize thinking and clinical decision making about clients' healthcare needs

The nurse encounters resistance when inserting the tubing into a client's rectum

As the client to relax and run a small amount of fluid into the rectum

A client is demonstrating a positive Chvostek's sign

Ask the client about numbness or tingling in the hands

A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis

Ask the client if this decision has been discussed with his healthcare provider

As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy

Ask the mother to be present to soothe the child

What action by the nurse demonstrates culturally sensitive care

Asks permission before touching a client

A signed consent form indicated a client should have an electromyogram

Assault and battery with deliberate intent to deviate from the consent form

The nurse is preparing to give a client with dehydration IV fluids delivered at a continuous rate of 175ml/hr

Cassette infusion pump

What intervention should the nurse include in the plan of care for a client who is being treated with an Unna's paste boot

Check capillary refill of toes on lower extremity with Unna's paste boot

In evaluating client care, which action should the nurse take first?

Determine if the expected outcomes of care were achieved

A 75-year-old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke

Determine who is legally empowered to make decisions

In assessing a client's femoral pulse

Document the presence and volume of the pulse palpated

An older female client with rheumatoid arthritis is complaining of severe joint pain

Drape the sheets over the footboard of the bed

When making the bed of a client who needs a bed cradle

Drape the top sheet and covers loosely over the bed cradle

The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique

Draw up the irrigating solution into the syringe

The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related to lack of motivation"

Eats anything and does not think diet makes a difference in health

A client provides the nurse with information about the reason for seeking care

Elicit specific facts about past hospitalizations with direct questions

Which client care requires the nurse to wear barrier gloves

Emptying the urinary catheter drainage bag for a client with Alzheimer's disease

A 35-year-old female client with cancer refuses to allow the nurse to insert an IV

Evaluate the client's mental status for competence to refuse treatment

A nurse is becoming increasingly frustrated by the family members' efforts

Examine one's own culturally based values, beliefs, attitudes, and practices

What activity should the nurse use in the evaluation phase of the nursing process

Examine the effectiveness of nursing interventions toward meeting client outcomes

The home health nurse visits an elderly client who lives at home with her husband

Fluid volume imbalance

The nurse overhears the healthcare provider explaining to the client that the tumor removed was non-malignant

Healthcare provider

A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments

Herbs should be obtained from manufacturers with a history of quality control of their supplements

What client statement indicates to the nurse that the client requires assistance with bathing

I don't understand why i'm so weak and tired

A male nurse is assigned to care for a female Muslim client

I will ask one of the female nurses to bathe you

A healthcare provider is performing a sterile procedure at a client's bedside

Identify the break in surgical asepsis and provide another set of sterile supplies

When caring for an immobile client what nursing diagnosis has the highest priority

Impaired gas exchange

A male client with venous incompetence stands up and his blood pressure subsequently drops

Increase in pulse rate

Which statement is an example of a correctly written nursing diagnosis statement

Ineffective coping related to response to positive biopsy test results

A client in hospice care develops audible gurgling sounds on inspiration

Inform the family that death is imminent

While preparing to insert a rectal suppository in a male adult client

Instruct the client to take slow deep breaths and stop bearing down

A 4-year-old boy who is schedule for a tonsillectomy and adenoidectomy

It may hurt but we'll give you medicine to help you feel better

The daughter of an older woman who became depressed following the death of her husband asks

It's highly likely that she will recover and return to her pre-illness state

When teaching a female client to perform intermittent self-catheterization

Locate the perineum

The charge nurse assigns a nursing procedure to a new staff nurse

Refuse to perform the task that is beyond the nurse's experience

The nurse is administering an intermittent infusion of an antibiotic to a client

Reposition the client's arm

Which client assessment data is most important for the nurse to consider before ambulating a postoperative client

Respiratory rate

The nurse nots that a client consistently coughs while eating and drinking

Risk for aspiration

A female client who has breast cancer with metastasis to the liver and spine is admitted

Sensory pattern, area, intensity, and nature of the pain

A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure

Serum albumin

The nurses determine a client's IV solution is infusing at 250ml/hr

Slow the IV infusion to keep vein open rate

While caring for a child and mother from Cambodia

Speak initially with the oldest family member to show respect

A client is admitted to the hospital with intractable pain

Take measures to promote as much comfort as possible

A single mother of two teenagers, ages 16 and 18,

Tell me what you would like to see happen with your children in the future

When assessing a client with an indwelling urinary catheter

The clamp on the urinary drainage bag is open

Which statement best describes durable power of attorney

The client signs a document that designates another person...

The nurse assesses an immobile, elderly male client and determines that his blood pressure is 138/60

Turn the client q2h

Which statement correctly identifies a written learning objective

Upon discharge, the client will list three ways to protect the feet from injury

A male client has a nursing diagnosis of "spiritual distress"

Use reflective listening techniques when the client expresses spiritual doubt

The nurse is discussing dietary preferences with a client who adheres to a vegan diet

Vitamin B12

A client is admitted with a stage four pressure ulcer that has a black, hardened surface

Wet to moist dressing

To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain

What activities during a routine ay are impacted by your pain

When the nurse enters a client's room to do an initial assessment the client shouts "Get out of my room! I'm tired of being bothered!"

What is concerning you this morning?

A nurse is preparing to insert a rectal suppository and observes a small amount of rectal bleeding

Withhold the administration of the suppository until contacting the healthcare provider

A male client arrives at the outpatient surgery center for a schedule needle aspiration of the knee

Witness the client's signature on the consent form

When preparing to administer an intravenous medication through a central venous catheter,

Flush the lumen with the saline solution and administer the medication through the lumen

A 73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition

Foods and liquids consumed during the past 24 hours

A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy

Generativity

A male client with an infected wound tells the nurse that he follows a macrobiotic diet

Combination of plant proteins to provide essential amino acids

In providing care for a terminally ill resident of a long-term care facility

Notify family members of the client's condition

A client who has been on bedrest for several days now has a prescription to progress activity as tolerated

Advise the client to sit on the sit of the bed for a few minutes before standing again

A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death."

Assist and support the client in establishing short-term goals

The charge nurse observes an unlicensed assistive personnel (UAP) bending at the waist

Bend at the knees when lifting heavy objects

A client with Raynaud's disease asks the nurse about using biofeedback

Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation

The nurse is completing the plan of care for a client who is admitted for benign prostatic hypertrophy

Complains of inability to empty bladder

What action should the nurse implement when adding sterile liquids

Consider the sterile field contaminated if it becomes wet during the procedure

A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy

Continue the gabapentin

When assessing a client with a nursing diagnosis of fluid volume deficit

Continue the planned nursing interventions to restore the client's fluid volume

The nurse is providing passive range of motion (ROM) exercises to the hip and knee

Cradle the client's heel

While the nurse is administering a bolus feeding to a client via nasogastric tube

Discontinue the administration of the bolus feeding

Before administering a client's medication, the nurse assesses a change in the client's condition

Document the events that occurred in the nurses' notes

A nurse observes a student nurse taking a copy of a client's medication administration record

Explain that the records are hospital property and may not be removed

After a client has been premedicated for surgery with an opiod analgesic

Notify the surgeon that the consent form has not been signed

Which nursing intervention is most beneficial in reducing the risk of urosepsis

Obtain a prescription for removal of the catheter as soon as possible