HESI RN FUNDAMENTALS TESTBANK
A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administer a dose that is not within the prescribed parameters. What action should the nurse take first? C
A) Determine if the pain was reliev...
hesi rn fundamentals testbank a postoperative client has three different prn analgesics prescribed for different levels of pain the nurse inadvertently administer a dose that is not within the presc
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HESI RN FUNDAMENTALS
TESTBANK
A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently
administer a dose that is not within the prescribed parameters. What action should the nurse take first? C
A) Determine if the pain was relieved.
B) Complete a medication error report.
C) Assess for side effects of the medication.
D) Document the clients responses.
The unlicensed assistive personnel (UAP) describes the appearance of the bowel movements of several clients.
Which descriptions warrant additional follow-up by the nurse? (Select all that apply.) ABDE
A) Multiple hard pellets.
B) Brown liquid.
C) Formed but soft.
D) 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 include in this client’s teaching plan? A
A) The importance of using vaginal lubricants.
B) Methods used to practice safe sex.
C) Information about alternative ways to express sexuality.
D) Intercourse positions that help prevent tears.
A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved,
and he is now able to sit In a wheelchair. To assist the client in transferring from the bed to a wheelchair, what action
should the nurse take?
A) Have the client put both arms around the nurse’s neck for support. B)
Place the wheelchair on the client’s left side.
C) Instruct the client to look at his feet.
D) Instruct the client total slow, deep breaths while transferring.
The nurse observes a newly admitted older adult female take short steps and walk very slowly while pushing a walker in
front of her. What action should the nurse take in response to these observations? A
A) Complete a full fall risk assessment of the client.
B) Teach the client to take longer steps at faster pace.
C) Suggest that the the client use a wheelchair instead of a walker.
D) Place client on bedrest until the healthcare provider is notified.
A client is receiving ketorolac (Toradol) IM 45 mg IM 6 hours for postoperative pain. The available 2 ml vial is
labeled , Toradol IM 30 mg/ml, How many should the nurse administer?
(Round to the nearest tenth.) 1.5mg
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 should the nurse take in response to this finding?
C
A) Reposition the pulse oximeter clip to obtain a new reading.
B) Stop suctioning until the pulse oximeter reading is above 95%. C)
Complete the intermittent suction of the nasopharynx.
D) Apply an oxygen mask over the client’s nose and mouth.
,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 action should the nurse take first? A
A) Discuss with the client her meaning of heroic measures.
B) Obtain a “do not resuscitate” (DNR) prescription.
C) Set up a family conference to discuss the client’s.
D) Consult the palliative care team about client’s care.
A client diagnosed with primary open-angle glaucoma received a prescription for biotic eye drops, pilocarpine HCl
(Pilocarpine). What instruction should the nurse plan to include in this client’s teaching? A
A) “Do not allow the dropper bottle to touch the eye.”
B) “Administer the medication directly on the cornea.”
C) “Squeeze your eye closed after administering the drops.”
D) “Wash your hands after each administration of eye drops.”
When assessing a client who starts to wheeze related data should obtain? D
A) Presence of radiation.
B) Heart sounds.
C) Body temperature. D)
Precipitating factors.
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 an unlicensed assistive personnel. (UAP) to provide routine foot care and file the
client’s toenails? Select all that apply.) ABC
A) syncope when bending.
B) Hand tremors.
C) Diminished visual acuity.
D) Urinary incontinence.
E) Shuffling gait.
A 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
A) Flush the catheter daily with sterile saline. B)
Encourage increased intake of oral fluids.
C) Administer a PRN antipyretic if a fever develops.
D) Secure the drainage bag at bladder level during transport.
To assess the quality of an adult client’s pain, what approach should the nurse use? C
A) Observe body language and movement.
B) Provide a numeric pain scale.
C) Ask the client to describe the pain.
D) Identify effective pain relief measures.
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” D
B) “Would you like me to call your minister?”
C) “Don't give up, you still have chemotherapy to try.” D)
“Yes, your condition is serious.”
When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse
implement first? C
A) Apply the blood pressure cuff securely.
B) Record the client’s pulse rate and rhythm. C)
Position the client supine for a few minutes.
D) Assist the client to stand at bedside.
,A female unlicensed assistive personnel (UAP) is assigned to take the vital signs of a client with pertussis for whom
droplet precautions have been implemented. The UAP request a change in assignment, stating she has not yet been fitted
for a particulate filter mask. What action should the nurse take? D
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 clients goals.
B) Determine if the expected outcomes were realistic.
C) Review related professional standards of care.
D) Obtain current client data to compare with expected outcomes.
A policy requiring the removal of acrylic nails by all nursing personnel was
implemented six months ago. Which assessment measure best determines if the
intended outcome of the policy is being achieved?
A) Number of the staff-induced skin injuries.
B) Client satisfaction survey.
C) Rate of needlestick injuries by nurses.
D) Healthcare-associated infection rates.
A client with limited tolerance for activity needs to walk in the hallway with
assistance. Which instructions should the nurse give to the unlicensed assisstive
personnel (UAP) who assissting with client’s care? (Select all that apply.)
A) Instruct the client about signs of orthostatic hypertension
B) Determine if the client needs to have a gait belt applied C)
Measure the clients vital signs before the client walks. D) Offer to
assist the client to void prior to walking in the hall. E) Report the
onset of any dizziness or light headedness.
A client has begun a long-term maintenance therapy with lithium, which has a
narrow therapeutic index. Which adverse effect is most important for nurse to
include in the teaching plan?
A) Dependence.
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?
A) The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace.
B) Completing the electronic record during an interview is a legal obligation of the examining nurse.
C) The nurse has limited ability to observe nonverbal communication
while entering the assessment electronically.
D) The client’s comfort level is increased when the nurse breaks eye contact to type notes into the record.
A client who lives in an assisted living facility develops cognitive impairment
following a stroke. Informed consent is needed to provide additional nursing
services. Who should nurse contact?
, A) The client’s oldest living child, a lawyer, who is visiting from out of town.
B) A daughter -in-law designated as the client’s Durable Power of Attorney (DPOA).
C) The client’s youngest son, identified by family members as the family spokesperson.
D) The client’s spouse who lives in the independent living unit of the facility.
A client is in contact isolation due to stage IV coccyx wound infected with
methicillin resistant staphylococcus aureus (MRSA). The nurse plans interventions
to prevent multiple re-entries to the client’s room. In which order should the nurse
perform the interventions?
A) Change coccyx dressing, perform tracheostomy care, restart the IV.
B) Perform tracheostomy care, change coccyx dressing, restart the IV.
C) Restart the IV, perform tracheotomy care, change coccyx dressing.
D) Change coccyx dressing, restart the IV, perform tracheostomy care.
What self-care outcome is best for the nurse to use in evaluating a client’s recovery
form 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 optimal level of capacity.
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