Fund Hesi Commonly missed

A registered nurse is educating a nursing student about the importance of nursing documentation for performing risk management. What information should the nurse give?

- A nurses documentation is the evidence of the care that a client receives - the nurse should note down assessments and significant changes in the clients health -nurses should always document the PCP's responses whenever they are contacted

A nurse is providing colostomy care to a client with a nosocomial infection caused by methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) should the nurse use

- gown -gloves -goggles

The client receives a prescription for tap water enemas until clear. The nurse is aware that no more than two enemas should be given at one time to prevent the occurrence of what?

- hypokalemia Repeated tap water enemas deplete cells and extracellular fluid of potassium and sodium, resulting in hypokalemia, hyponatremia, and the potential for water intoxication.

A client with a bleeding disorder is taking intravenous coagulant medications. The client suddenly develops an embolic stroke as a result of drug overdose. Which actions by the hospital management does the Leapfrog Group suggest?

-Apologize to client's family - Waive all fees rt the adverse effect -Report adverse event to Joint Commission -The aim of the Leapfrog Group is to make health care safer. In case of an adverse event, the Leapfrog Group suggests that the hospitals apologize to the client and family. It also suggests waiving all costs directly related for the treatment of adverse effects. According to the Leapfrog Group, the hospital should report the adverse event to The Joint Commission and take measures to prevent this error in the future.

A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take?

Don a N95 respirator mask before entering the room

A client reports vomiting and diarrhea for 3 days. Which clinical indicator is most commonly used to determine whether the client has a fluid deficit

Loss of body weight Dehydration is most readily and accurately measured by body weight.

A nurse is caring for an elderly client who has constipation. Which independent nursing intervention helps to reestablish a normal bowel pattern?

Offer a cup of prune juice - you don't need the provider to offer prune juice - prune juice helps to promote bowel movement because it contains sorbitol that increases water retention in feces

A client being treated for influenza A (H1N1) is scheduled for a computed tomography (CT) scan. To ensure client and visitor safety during transport, the nurse should take which precaution?

Place a surgical mask on the client -Nurses should provide influenza clients with face masks to wear for source control and tissues to contain secretions when outside of their room. Special precautions such as face masks should be taken to decrease the risk of further outbreak.

Which assessment finding is associated with depression

islands of intact memory Depression may occur with major changes in life. A client with depression has selective or patchy memory loss with islands of intact memory.

Define titrate

to continuously measure and adjust the balance of

A nurse is taking care of a client who has chronic back pain. What nursing considerations should be made when determining the client's plan of care?

- ask the client about a tolerable level of pain - administer pain medications regularly around the clock

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency?

- leg cramps -muscle weakness -Leg cramps occur with hypokalemia because of potassium deficit. Muscle weakness occurs with hypokalemia because of the alteration in the sodium potassium pump mechanism

The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration?

Change in mental status - older people are more sensitive to fluid and electrolyte imbalances. Changes manifest in LOC changes and confusion

The nurse receives a report on a newly admitted client who is positive for Clostridium difficile. Which category of isolation would the nurse implement for this client?

Contact precautions

A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution?

Cover the infected site with a dressing - Covering the infected site with a dressing will contain secretions and set up a barrier, thus decreasing the risk for transmission to others. Contact precautions must be used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment.

A primary healthcare provider prescribes a urinalysis for a client with an indwelling catheter. To ensure that an appropriate specimen is obtained, the nurse would obtain the specimen from which site?

Tubing injection port - The appropriate site to obtain a urine specimen for a client with an indwelling catheter is the injection port. The nurse should clean the injection port cap of the catheter drainage tubing with appropriate antiseptic, attach a sterile 5-mL syringe into the port, and aspirate the quantity desired.

A geriatric client with hypertension and diabetes mellitus is taking propranolol (Inderal) and insulin (Humulin N) therapy. Which interventions by health care professionals help prevent client medication errors according to the Leapfrog Group?

Using computer physician order entry -The Leapfrog Group suggests using computer physician order entry (CPOE) to prevent medication errors. CPOE provides immediate information to the primary healthcare providers and nurses about the medications prescribed to the clients and helps prevent drug interactions and adverse effects

Define Sentinel Event?

an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof (so death would be sentinel, a seizure would be considered "adverse")

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.