Advise the client to sit on the side of the bed for a few minutes before standing again. Which technique is most important for the nurse to implement when performing a physical assessment? A consistent, systematic approach. A healthcare provider is performing a sterile procedure at a client’s bedside. Show
Which technique should the nurse use when communicating with Jamie about her terminal illness?Which technique should the nurse use when communicating with Jamie about her terminal illness? Respect the client’s pattern of communication and ways of dealing with stress. Which action should the nurse implement when using the confrontation?Which action should the nurse implement when using the confrontation technique during a vision exam? Sit facing the client and while look directly at the client’s face, move an object inward from the periphery. You might be interested: FAQ: Where Is Hospice Provided? Which statement by Jill indicates an understanding of palliative care?After collaborating with her healthcare providers, Jill has decided to pursue palliative care. Which statement by Jill indicates an understanding of palliative care? All of my treatments and medications will need to be discontinued. I will discontinue any treatments and only take medications that will help my pain. What actions should a nurse implement when a client refuses a treatment?Recognize the client’s right to refuse treatment/procedures. Discuss treatment options/decisions with client. Provide education to clients and staff about client rights and responsibilities. Evaluate client/staff understanding of client rights. What are the reasons nurses should manage professional stress?What are the reasons nurses should manage professional stress? To avoid nurse burnout. To safeguard client safety. To promote self-absorption. Which behavior is inconsistent with depression?Depressive patients are more impulsive and inconsistent in intertemporal choice behavior for monetary gain and loss than healthy subjects–an analysis based on Tsallis’ statistics. Neuro Endocrinol Lett. What is the safest manner of giving oral care to Bertha?What nursing intervention should be instituted to care for Bertha’s mouth? Clean her mouth frequently with oral swabs. What is the safest manner of giving oral care to Bertha? Have two nurses or UAPs perform the procedure. Which foods should the nurse instruct a client diagnosed with end stage renal disease to avoid?The client diagnosed with end–stage renal disease needs to avoid foods high in potassium such as bananas, high in sodium such as colas and high in protein such as red meats. Which action would the nurse do first when planning to provide a back massage to a client?Which action would the nurse do first when planning to provide a back massage to a client? Assess the client’s preference for touch and massage. Which type of delivery of nursing care is organized around tasks?“Functional nursing is organized around tasks.” Which of the following statements shows the nurses understanding of primary nursing? “Primary nursing involves one nurse planning care for the patient.” 
Fundamentals Hesi Review
A post-operative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What action should the nurse take first?
C: Assess for side effects of the medication.
The UAP describes the appearance of the bowel movements of several clients. Which descriptions warrant additional follow-up by the nurse?(SATA)A: Multiple hard pelletsB: Brown liquidC: Formed but softD: Solid with red streaks E: Tarry appearance
An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vaginal tear, which the client reports is likely to have occurred during unprotected sexual intercourse. Which content is most important for the nurse to inc
A: The importance of using vaginal lubricants.
While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action would the nurse take in response to this finding?
C: Complete the intermittent suction of the nasopharynx.
An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What actions should the nurse take first?
A: Discuss with the client her meaning of heroic measures.
A client diagnosed with primary open-angle glaucoma received a prescription for biotic eye drops, pilocarpine HCl. What instruction should the nurse plan to include in this client's teaching?A: "Do not allow the dropper bottle to touch the eye." B: "Admi
A: "Do not allow the dropper bottle to touch the eye.
The home health nurse is reviewing the personal care of an elderly client who lives alone. Which client assessment findings indicate the need to assign the UAP to provide routine foot care and file the client's toenails?(SATA)A: Syncope when bending. B:
The client is discharged to a long-term care facility with an indwelling urinary catheter. Which nursing action should be included in the plan to reduce the client's risk for infection related to the catheter?
B: Encourage increase intake of oral fluids.
A client who has been diagnosed with terminal cancer tells the nurse, "The doctor told me I have cancer and do not have long to live." Which response is best for the nurse to provide?A: "That's correct. You do not have long to live." B: "Would you like m
D: "Yes, your condition is serious.
When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first?A: Apply the blood pressure cuff securely.B: Record the client's pulse rate and rhythm. C: Position the client supine for a f
C: Position the client supine for a few minutes.
When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?A: Modify the nursing interventions to achieve the client's goals. B: Deter
D: Obtain current client data to compare with expected outcomes.
A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instructions should the nurse give to the UAP who is assisting with the client's care?(SATA)A: Instruct the client about signs of orthostatic hypertension. B
A client has begun a long-term maintenance therapy with lithium, which has a narrow therapeutic index. Which adverse effect is most important for the nurse to include in the teaching plan?A: Dependance.B: Toxicity.C: Interaction. D: Tolerance.
While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?
C: The nurse has limited ability to observe nonverbal communication while entering the assessment electronically.
What self-care outcome is best for the nurse to use in evaluating a client's recovery from a stroke that resulted in left-sided hemiparesis?A: Promote independence by allowing client to perform all self care activities. B: Participates in self care to op
C: Client verbalizes importance of hygienic practices in the recovery process.
A female nursing home resident and her family only speak Spanish. During a visit, the entire family begins to cry hysterically. When unable to determine why the family is upset, what intervention is most important for the nurse to implement?
C: Close the door to the client's room to provide family privacy.
A male client with limited mobility is discharged with home heath services. When the home health nurse arrives, the client asks what he can do for the swelling in his legs. Which should the nurse implement?
D: Advise the client to flex both of his feet several times a day.
The home care nurse is teaching a client how to change the dressing on a new venous stasis ulcer. The client has a history of a deep vein thrombosis and has an allergy to latex. When removing the adhesive bandages, the nurse observes skin redness surround
C: Obtain sample of the drainage for culture.
The nurse measures the client's blood pressure and notes that it is significantly higher than the previous reading. What should the nurse do next?(SATA)A: Retake the client's blood pressure in the opposite arm. B: Ask another nurse to assist in assessing
A client is admitted with pneumonia and has a recent history of MRSA. The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?
A middle-aged male client tells the nurse that weeks ago he began exercising four times a week to lose weight and to help him sleep better. He states that it still takes an hour to fall asleep at night. What action should the nurse implement?
D: Ask the client to describe the exercise schedule that he has been following.
A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that he has chronic constipation and had not had a bowel movement in 5 days, despite trying several home remedies. Which intervention is mos
A: Determine what home remedies were used.
What information is most important for the nurse to obtain in determining a client's need for referral for obesity counseling?A: Body weight 10% over ideal weight.B: Body mass index greater than 35.C: Daily caloric intake of 3500 calories. D: Client's
B: Body mass index greater than 35.
A client who has been taking diuretics for premenstrual swelling reports muscle weakness. Which serum electrolyte value should the nurse report to the healthcare provider?A: Potassium 3.1 mEq/LB: Sodium 142 mEq/LC: Total calcium 9.2 mg/dl D: Chloride 9
A nurse is caring for a male client with diminished circulation in the lower extremities. The client washes his feet in the shower but is unable to bend safely to dry his feet. While drying the client's feet, the nurse should emphasize the need to thoroug
A client on a prescribed full liquid diet has a nursing diagnosis of "Risk for impaired skin integrity related to reduced oral intake." What snack is best to provide this client?A: Beef broth or chicken broth.B: Purified lowfat milk. C: Apple or grapefr
D: Ensure, a liquid supplement.
The healthcare provider prescribes bladder irrigation to maintain patency of a client's indwelling urinary catheter. Which intervention should the nurse implement?A: Use a sterile syringe to irrigate with NS 20 ml. B: Use an infusion pump to slowly irrig
A: Use a sterile syringe to irrigate with NS 20 ml.
Two nurses assess a client for a pulse deficit and count an apical pulse of 72 beats/minute and a radial pulse of 88 beats/minute. What action should the nurse take first?A: Obtain a second pulse deficit reading. B: Report the results to the healthcare p
B: Report the results to the healthcare provider.
A 24-hour urine collection is in progress. The client tells the nurse that the last voiding was accidentally flushed instead of saved in the container. What interventions should the nurse initiate?A: Discard the urine and start another 24 hour period. B:
A: Discard the urine and start another 24 hour period.
A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save his life. The healthcare provider knows the client has good prognosis and refuses to write a DNR prescription. What acti
A: Initiate an ethics committee review of the case.
A confused elderly male client is having trouble sleeping at night and is sometimes found wondering in the hallway. What nursing intervention should the nurse implement first?A: Apply wrist restraints to prevent wandering. B: Provide a back rub at bedtim
B: Provide a back rub at bedtime.
The nurse is preparing to feed a newly administered elderly male client who is debilitated but is able to respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain?
C: Client's ability to chew and swallow.
The nurse enters the room of a client with Clostridium difficile infection to administer an IV antibiotic. The UAP is in the room cleaning the client's buttocks and states the client has been incontinent with diarrhea. The UAP is wearing gloves but not a
A: Advise the UAP to put on a gown.
After reviewing the admission assessment of a client with chronic pain, which interventions should the nurse include in this client's plan of care?(SATA)A: Provide comfort measures such as topical warm application and tactile massage. B: Encourage increa
The grandmother of a young adult male admitted to the psychiatric unit yesterday requests information about her grandson's treatment plan. Before answering the family member's questions, what action should the nurse take?
B: Ensure that the signed release of information includes the grandmother.
The home health nurse visits a client who has a serum sodium level of 123 mEq/L. To explore possible etiologies for this value, what question should the nurse ask this client?A: "How frequently do you eat processed or canned foods?" B: "Do you drink milk
C: "How much water and ice chips do you have each day?
The client in the outpatient clinic complains of experiencing hard, infrequent stools. Which instruction should the nurse provide this client?A: "Walk around the block, or further, every day."B: "Take an over-the-counter laxative every morning." C: "Try
D: "Drink six to eight large glasses of water daily.
The nurse is planning care for a group of patients on a Med-Surg unit during night shift. Which patient should be closely monitored for sleep apnea?A: A woman with restless leg syndrome and COPD. B: A young woman taking Coumadin and has a diagnosis of in
D: A male with multiple problems including diabetes, HTN, and obesity.
A nurse is discharging a patient who has been hospitalized for the last 5 days with pneumonia. While providing discharge instructions, the client is noticeably anxious. What action is the most important for the nurse to implement?
C: Provide written discharge instructions.
A client is 2 days post-op from a thoracic surgery and is complaining of incisional pain. The client last received pain medication 2 hours ago. He is rating his pain a 5 on a 1-10 scale. After calling the provider, what is the nurse's next action?
A: Encourage the client to use guided imagery and slow, rhythmic breathing.
It is most important for a nurse to recalculate a patient's Braden score who develops which problem?A: Urinary incontinence.B: Hypoactive bowel sounds.C: Weakened cough reflex. D: 2+ pitting edema to both legs.
Prior to attempting a digital removal of a fecal impaction, it is most important to perform which assessment?A: Bowel sounds.B: Vital Signs.C: Breath sounds. D: Abdominal girth.
Which technique is most important for the nurse to implement when performing a physical assessment?A: A head-to-toe approach.B: The medical systems approach.C: A consistent, systematic approach. D: An approach related to a nursing model.
C: A consistent, systematic approach.
The nurse is providing passive ROM exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next?A: Raise the bed to a comfortable working level. B: Bend the client
D: Cradle the client's heel.
Which assessment finding is most significant in determining the level of assistance a client requires with personal care?A: 2+ pitting edema in the lower extremities.B: Disorientation to person, place, and time.C: A red rash in the groin area. D: Firm
B: Disorientation to person, place, and time.
A male client with chronic debilitating heart disease asks the nurse to help him die because he believes that he will be better off dead rather than living under the current circumstances. The nurse supports the client and considers providing the family w
B: The nurse will be prosecuted for the murder of the client.
The nurse is preparing to irrigate the client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves?A: Empty the client's urinary drainage bag. B: Draw up the irrigating solution into the syringe.
B: Draw up the irrigating solution into the syringe.
What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile?A: Maintain in a lateral position using protective wrist and vest devices.B: Position prone with a small pillow below the diaphragm. C: Raise
B: Position prone with a small pillow below the diaphragm.
The nurse is administering an intermittent infusion of an antibiotic to a client whose IV access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action s
B: Reposition the client's arm.
A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements?
C: Herbs should be obtained from manufacturers with a history of quality control of their supplements.
A high school senior is complaining of a persistent cough and admits to smoking 10 to 15 cigarettes daily for the past year. He is convinced that he is hopelessly addicted to tobacco since he tried unsuccessfully to quit smoking last week. Which intervent
A: Encourage the student to associate with non-smokers only while attempting to stop smoking.
A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first?A: Hydrogel.B: Exudate absorber. C: Wet to moist dres
C: Wet to moist dressing.
Which action should the nurse implement when using the confrontation technique during a vision exam?A: Use an Ophthalmoscope to watch the client's pupil constrict when a strong light is shown into it. B: Stand behind the client and direct the client to t
D: Sit facing the client and while looking directly at the client's face, move an object inward from the periphery.
When caring for an immobile client, what nursing diagnosis has the highest priority?A: Risk for fluid volume deficit.B: Impaired gas exchange.C: Risk for impaired skin integrity. D: Altered tissue perfusion.
B: Impaired gas exchange.
The nurse explains that which of the following are goals of palliative care?(SATA)A: Delays death.B: Offers a support system.C: Provides pain management.D: Focuses only on the patient, not the family.E: Manages symptoms of disease. F: Enhances qualit
What clinical manifestations would indicate to the nurse that a patient is possibly experiencing orthostatic hypotension?(SATA)A: NauseaB: LightheadednessC: DizzinessD: Patient c/o seeing spots.E: Flushing face. F: Bradycardia.
The nurse assess an elderly, immobilized male patient, BP: 138/7, Temp: 96.9, urine output=100ml concentrated urine in the last hour. He has increased respiratory secretions and wet lung sounds. Which nursing action is the most important to implement? |
Which action should the nurse implement when using the confrontation technique during a vision exam?
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