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