Exam (elaborations)
HESI NCLEX-RN Fundamentals 2024/2025 graded A+
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HESI NCLEX-RN Fundamentals 2024/2025 graded A+
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HESINCLEX-RN
Fundamentals
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?
-
ANSTaking
anticoagulants
for
the
past
year
Rationale:
Anticoagulants
(B)
increase
the
risk
for
bleeding
during
surgery,
which
can
pose
a
threat
for
developing
surgical
complications.
The
healthcare
provider
should
be
informed
that
the
client
is
taking
such
drugs.
Urinary
catheterization
is
prescribed
for
a
postoperative
female
client
who
has
been
unable
to
void
for
8
hours.
The
nurse
inserts
the
catheter,
but
no
urine
is
seen
in
the
tubing.
What
action
will
the
nurse
take
next?
-
ANSLeave
the
catheter
in
place
and
reattempt
with
another
catheter.
Rationale:
It
is
likely
that
the
first
catheter
is
in
the
vagina,
rather
than
the
bladder.
Leaving
the
first
catheter
in
place
will
help
locate
the
meatus
when
attempting
the
second
catheterization
The
nurse
is
instructing
a
male
client
in
the
proper
use
of
a
metered-dose
inhaler.
Which
instruction
should
the
nurse
provide
the
client
to
ensure
the
optimal
benefits
from
the
drug?
-
ANSCompress
the
inhaler
while
slowly
breathing
in
through
your
mouth.
Rationale:
The
medication
should
be
inhaled
through
the
mouth
simultaneously
with
compression
of
the
inhaler
The
nurse
is
assisting
a
male
client
to
the
bathroom.
When
5
feet
from
the
bathroom
door,
the
client
states,
"I
feel
faint."
Before
the
nurse
can
get
him
to
a
chair,
he
starts
to
fall.
What
is
the
priority
action
for
the
nurse
to
take?
-
ANSGently
lower
the
client
to
the
floor.
Rationale:
(D)
is
the
most
prudent
intervention
and
is
the
priority
nursing
action
to
prevent
injury
to
the
client
and
the
nurse.
Lowering
the
client
to
the
floor
should
be
done
when
the
client
cannot
support
his
own
weight.
The
client
should
be
placed
in
a
bed
or
chair
only
when
sufficient
help
is
available
to
prevent
injury.
Which
nursing
diagnosis
has
the
highest
priority
when
planning
care
for
a
client
with
an
indwelling
urinary
catheter?
-
ANSHigh
risk
for
infection
Rationale:
Indwelling
urinary
catheters
are
a
major
source
of
infection
A
nurse
is
working
in
an
occupational
health
clinic
when
a
male
employee
walks
in
and
states
that
he
was
struck
by
lightning
while
working
on
his
truck
bed.
He
is
alert
but
reports
feeling
faint.
What
assessment
will
the
nurse
perform
first?
-
ANSPulse
characteristics
Rationale: Lightning
is
a
jolt
of
electrical
current
and
can
produce
a
"natural"
defibrillation,
so
assessment
of
the
pulse
rate
and
regularity
(A)
is
a
priority.
Since
the
client
is
talking,
he
has
an
open
airway
The
nurse
makes
the
nursing
diagnosis
of
Potential
for
infection
related
to
partial-thickness
(second-degree)
and
full-thickness
(third-degree)
burns.
What
intervention
has
the
highest
priority
in
decreasing
the
client's
risk
of
infection?
-
ANSUse
of
careful
handwashing
technique
Rationale:
Careful
handwashing
technique
(B)
is
the
single
most
effective
intervention
for
prevention
of
contamination
to
all
clients.
When
taking
a
client's
blood
pressure,
the
nurse
is
unable
to
distinguish
the
point
at
which
the
first
sound
was
heard.
What
is
the
best
action
for
the
nurse
to
take?
-
ANSDeflate
the
cuff
to
zero
and
wait
30
to
60
seconds
before
reattempting
the
reading.
Rationale:
Deflating
the
cuff
for
30
to
60
seconds
(C)
allows
blood
flow
to
return
to
the
extremity
so
that
an
accurate
reading
can
be
obtained
on
that
extremity
a
second
time.
The
nurse
observes
an
unlicensed
assistive
personnel
(UAP)
taking
a
client's
blood
pressure
in
the
lower
extremity.
Which
observation
of
this
procedure
requires
the
nurse's
intervention?
-
ANSThe
UAP
auscultates
the
popliteal
pulse
with
the
cuff
on
the
lower
leg.
Rationale:
When
obtaining
the
blood
pressure
in
the
lower
extremities,
the
popliteal
pulse
is
the
site
for
auscultation
when
the
blood
pressure
cuff
is
applied
around
the
thigh.
The
nurse
should
intervene
with
the
UAP
who
has
applied
the
cuff
on
the
lower
leg
In
taking
a
client's
history,
the
nurse
asks
about
the
stool
characteristics.
Which
description
should
the
nurse
report
to
the
healthcare
provider
as
soon
as
possible?
-
ANSDaily
black,
sticky
stool
Rationale:
Black,
sticky
stool
(melena)
is
a
sign
of
gastrointestinal
bleeding
and
should
be
reported
to
the
healthcare
provider
promptly
The
nurse
is
teaching
a
male
client
how
to
perform
progressive
muscle
relaxation
techniques
to
relieve
insomnia.
A
week
later
the
client
reports
that
he
is
still
unable
to
sleep
despite
following
the
same
routine
every
night.
What
action
should
the
nurse
take
first?
-
ANSAsk
the
client
to
describe
the
routine
he
is
currently
following.
Rationale:
The
nurse
should
first
evaluate
whether
the
client
has
been
adhering
to
the
original
instructions
By
rolling
contaminated
gloves
inside
out,
the
nurse
is
impacting
which
step
in
the
chain
of
infection?
-
ANSMode
of
transmission
Rationale:
The
contaminated
gloves
serve
as
the
mode
of
transmission
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