HESI COMPREHENSIVE FINAL EXAM 2022 | ALL Questions deeply explained & Graded-When establishing realistic goals, the nurse:
A. Bases the goals on the nurse's personal knowledge.
B. Knows the resources of the health care facility, family, and the client.
C. Must have a client who is physically and...
the nurse a bases the goals on the nurses personal knowledge b knows the resources of the health care facility
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HESI COMPREHENSIVE FINAL EXAM
2022
When establishing realistic goals, the nurse:
A. Bases the goals on the nurse's personal knowledge.
B. Knows the resources of the health care facility, family, and the client.
C. Must have a client who is physically and emotionally stable.
D. Must have the client's cooperation. - Ans: B
A client is ordered to receive an intramuscular injection of medication. When preparing to administer
the injection, the nurse selects the ventrogluteal site based on which reason?
a. there is a high possibility of injecting into subQ fat
b. the area is free of major blood vessels and fat
c. the site lies close to the radial nerve
d. the site is in close proximity to the sciatic nerve - b. the area is free of major blood vessels and fat
The student nurse is preparing to administer medication through a feeding tube. Which of the
following statements if made by the student nurse indicates correct understanding?
A) "I will perform hand hygiene. Gloves are only necessary for tube insertion, not medication
administration."
B) "The head of the bed should be kept flat during medication administration."
C) "I will aspirate gastric contents to check placement of the feeding tube and residual volume and
then I will dispose of the aspirate properly.
D) "I will flush with 10 mL of tap water after each medicine and with 30-60 mL of water after the last
medication." - D
A nursing measure to promote sleep in school-age children is to:
1. Make sure the room is dark and quiet
2. Encourage evening exercise
3. Encourage television watching
4. Encourage quiet activities prior to bed time. - 4. Encourage quiet activities prior to bed time.
The amount of sleep needed during the school years is individualized because of varying states of
activities and levels of health. A 6-year old averages 11-12 hours of sleep nightly, whereas an 11-year
old sleeps about 9-10 hours. The 6- or 7-year old can usually be persuaded to go to bed by
encouraging quiet activities.
,A female client verbalizes that she has been having trouble sleeping and feels wide awake as soon as
getting into bed. The nurse recognizes that there are many interventions the promote sleep. Check all
that apply.
1. Eat a heavy snack before bedtime
2. Read in bed before shutting out the light
3. Leave the bedroom if you are unable to sleep
4. Drink a cup of warm tea with milk at bedtime
5. Exercise in the afternoon rather than the evening
6. Count backwards from 100 to 0 when your mind is racing. - Answer: 3, 5, and 6.
Lying in bed when one is unable to sleep increases frustration and anxiety which further impede
sleep; other activities, such as reading or watching television, should not be conducted in bed.
Counting backwards requires minimal concentration but it is enough to interfere with thoughts that
distract a person from falling asleep.
A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's
priority?
A. Complete a fall-risk assessment.
B. Educate the client and family about fall risks.
C. Eliminate safety hazards from the client's environment.
D. Make sure the client uses assistive aids in his possession - A. Complete a fall-risk assessment.
When a fall results in injury and hospitalization, a cycle of disuse may occur over time. When
establishing a care plan for the patient and family to prevent this, it is important to remember disuse is
most likely a result of:
A. Decreasing muscle strength.
B. Decreased joint mobility.
C. Fear of repeated falls.
D. Changes in sensory perception. - C. Fear of repeated falls.
A home health nurse is completing a home assessment for safety risks for a new older adult patient.
Which one of the following home observations is in most need of modification?
A) The temperature of common area rooms is kept at 72°F.
B) Carpeting is glued down with no holes or frayed edges and tile floors are intact.
C) An area rug is placed in front of the sink and toilet in the patient's bathroom.
D) A three-prong grounded extension cord is in good condition. - C) An area rug is placed in front of
the sink and toilet in the patient's bathroom.
,Area rugs present a fall risk and should not be used by the older adult in the bathroom. The nurse
should identify the risk, instruct the patient to remove the area rug, and ensure that the patient
verbalizes an understanding of these instructions. On the second visit, the nurse (or another member
of the health care team) should make sure that the rug was removed so that the risk is eliminated. The
temperature is pleasant and comfortable and presents no risk. The glued-down carpeting is not
movable and does not present a fall risk. The three-prong extension cord is in good condition and out
of a common pathway, so it does not present a fall risk.
A home care nurse is conducting a home assessment evaluation for an older adult's bathroom. Which
findings should the nurse identify as safety issues for the patient?
A) A tub bench in the bathtub
B) Diffuse lighting in the bathroom
C) A liquid soap bottle for the bathtub and sink
D) The absence of grab bars - D) The absence of grab bars
General fall prevention guidelines for the older adult's bathroom include grab bars in the tub, in the
shower, and near the toilet. A tub bench in the bathtub ensures a patient a place to sit during a shower
and decreases the risk of falls. Good lighting helps the patient see better in the bathroom, and diffuse
lighting is often better than one direct light source. Bar soaps should be replaced with liquid soaps.
A nurse who works in a skilled nursing facility is looking for ways to reduce the incidence of falls
among the residents. Which of the following recommendations by the nurse will decrease the greatest
number of falls in the facility?
A) Install nightlights in all the residents' bathrooms.
B) Complete a fall history and assessment for each resident upon admission.
C) Refer residents who need assistance with ambulation to occupational therapy.
D) Provide side rails on the beds to keep residents from falling out of bed. - B) Complete a fall
history and assessment for each resident upon admission.
Each resident should have a fall risk assessment upon admission to any nursing facility. This will help
identify high risk residents. Nightlights will help when going to the bathroom but is not generalized
enough to reduce all types of falls. Residents who need assistance to ambulate might need a referral
to physical or occupational therapy, but this will not reduce falls as much as comprehensive
assessments. Side rails to keep residents in bed are restraints; a better option would be low beds.
According to Erikson's Theory of development, which of the following older adults has successfully
navigated the stage of ego integrity versus despair?
A. A 70-year-old man who is reluctant to retire because work is everything to him.
B. 78-year-old woman who has scheduled her third face lift.
, C. 80-year-old man who has informed his children that he has made his funeral arrangements.
D. 67-year-old woman who is depressed because she has not been promoted at work for the past 10
years. - C. 80-year-old man who has informed his children that he has made his funeral arrangements.
Successfully navigating the stage of ego integrity versus despair requires that the individual accept
normal bodily changes associated with aging, find meaning in life apart from work, accepts the
inevitability of death, and is at peace with his or her life.
Characteristic behaviors of older adults who have successfully met Erikson's ego integrity versus
despair developmental task include:
A. Fear of death.
B. Feelings that life has been lived in vain.
C. Identity is related to career and work only.
D. Honest acceptance of the life that has passed. - D. Honest acceptance of the life that has passed.
Ego integrity versus despair is the developmental stage of older adults. The quality associated with
successful passage of this stage is integrity, defined as an honest acceptance of the life that has passed
and the stage of life that is currently being lived. Individuals who have reached this stage are said to
be at peace with themselves. The inability to reach this stage leads to fear of death and despair that
life has been lived in vain. Ego differentiation, which is a part of the developmental stage of ego
integrity, involves achieving an identity apart from work.
The nurse is caring for the client with pneumonia. An expected client outcome is, The client will
maintain adequate
oxygenation by discharge. Which outcome criterion indicates the goal is met?
A) Client taking antibiotic as ordered.
B) Client identifies signs and symptoms of recurrence of infection.
C) Client coughing and deep breathing every one hour.
D) Client no longer requires oxygen. - Ans: D
The client who is maintaining adequate oxygenation would not require oxygen. The client could be
able to do the other three options and still have problems with oxygenation.
A 70-year-old female patient who has had a number of strokes refuses further life-sustaining
interventions, including artificial nutrition and hydration. She is competent, understands the
consequences of her actions, is not depressed, and persists in refusing treatment. Her doctor is
adamant that she cannot be allowed to die this way, and her daughter agrees. An ethics consult has
been initiated. Who would be the appropriate decision maker?
a. Patient
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