HESI RN Fundamentals
Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG)
tube to suction for the past week?
Sodium
Rationale: Monitoring serum sodium levels (D) for hyponatremia is indicated during prolonged NG
suctioning because of loss of f...
hesi rn fundamentals which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric ng tube to suction for the past week sodium rationale monitoring serum sodiu
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HESI RN Fundamentals
Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG)
tube to suction for the past week?
Sodium
Rationale: Monitoring serum sodium levels (D) for hyponatremia is indicated during prolonged NG
suctioning because of loss of fluids.
When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?
With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into
the chair.
Rationale: (B) describes the correct positioning of the nurse and affords the nurse a wide base of support
while stabilizing the client's knees when assisting to a standing position. The chair should be placed at a
45-degree angle to the bed, with the back of the chair toward the head of the bed
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by
gravity has slowed, even though the venous access site is healthy. What should the nurse do next?
Check for kinks in the tubing and raise the IV pole.
Rationale: The nurse should first check the tubing and height of the bag on the IV pole (B), which are
common factors that may slow the rate. Gravity infusion rates are influenced by the height of the bag,
tubing clamp closure or kinks, needle size or position, fluid viscosity, client blood pressure (crying in the
pediatric client), and infiltration.
The nurse is assessing several clients prior to surgery. Which factor in a client's history poses the greatest
threat for complications to occur during surgery?
Taking anticoagulants for the past year.
Rationale:
Anticoagulants (B) increase the risk for bleeding during surgery, which can pose a threat for the
development of surgical complications. The health care provider should be informed that the client is
taking these drugs.
The nurse is administering the 0900 medications to a client who was admitted during the night. Which
client statement indicates that the nurse should further assess the medication order?
"This is a new pill I have never taken before."
Rationale:
The client's recognition of a "new" pill requires further assessment (D) to verify that the medication is
correct, if it is a new prescription or a different manufacturer, or if the client needs further instruction.
Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that
apply.)
A.
Place the client in a side-lying position.
B.
,Pull the auricle upward and outward.
C.
Hold the dropper 6 cm above the ear canal.
D.
Place a cotton ball into the inner canal.
E.
Pull the auricle down and back
Rationale:
The correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held
1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The
auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E).
A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is
important for the nurse to provide?
A. Decrease intake of fluids after the evening meal.
B. Drink a glass of cranberry juice every day.
C. Drink a glass of warm decaffeinated beverage at bedtime.
D. Consult the health care provider about a sleeping pill.
Rationale:
Nocturia is urination during the night. (A) is helpful to decrease the production of urine, thus decreasing
the need to void at night. (B) helps prevent bladder infections. (C) may promote sleep, but the fluid will
contribute to nocturia. (D) may result in urinary incontinence if the client is sedated and does not awaken
to void.
The nurse teaches the use of a gait belt to a male caregiver whose wife has right-sided weakness and
needs assistance with ambulation. The caregiver performs a return demonstration of the skill. Which
observation indicates that the caregiver has learned how to perform this procedure correctly?
A. Standing on his wife's strong side, the caregiver is ready to hold the gait belt if any evidence of
weakness is observed.
B. Standing on his wife's weak side, the caregiver provides security by holding the gait belt from the
back.
C. Standing behind his wife, the caregiver provides balance by holding both sides of the gait belt.
D. Standing slightly in front and to the right of his wife, the caregiver guides her forward by gently
pulling on the gait belt.
, Rationale:
His wife is most likely to lean toward the weak side and needs extra support on that side and from the
back (B) to prevent falling. (A, C, and D) provide less security for her.
A female nurse is assigned to care for a close friend, who says, "I am worried that friends will find out
about my diagnosis." The nurse tells her friend that legally she must protect a client's confidentiality.
Which resource describes the nurse's legal responsibilities?
A. Code of Ethics for Nurses
B. State Nurse Practice Act
C. Patient's Bill of Rights
D. ANA Standards of Practice
Rationale:
The State Nurse Practice Act (B) contains legal requirements for the protection of client confidentiality
and the consequences for breaches in confidentiality. (A) outlines ethical standards for nursing care but
does not include legal guidelines. (C and D) describe expectations for nursing practice but do not address
legal implications.
The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that
parental consent has not been obtained. Which action should the nurse take?
A. Review the chart for a signed consent for hospitalization.
B. Get the health care provider's permission to give the medication.
C. Do not give the medication and document the reason.
D. Complete an incident report and notify the parents.
Rationale:
The nurse should not give the medication and should document the reason (C) because the client is a
minor and needs a guardian's permission to receive medications. Permission to give medications is not
granted by a signed hospital consent (A) or a health care provider's permission (B), unless conditions are
met to justify coerced treatment. (D) is not necessary unless the medication had previously been
administered.
An older adult who recently began self-administration of insulin calls the nurse daily to review the steps
that should be taken when giving an injection. The nurse has assessed the client's skills during two
previous office visits and knows that the client is capable of giving the daily injection. Which response by
the nurse is likely to be most helpful in encouraging the client to assume total responsibility for the daily
injections?
A. "I know you are capable of giving yourself the insulin."
B. "Giving yourself the injection seems to make you nervous."
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