Exam (elaborations)
HESI Test Bank-Fundamentals updated 2024.
- Course
- Nursing
- Institution
- Rasmussen College
HESI Test Bank-Fundamentals updated 2024.
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HESI Test Bank-Fundamentals updated 2024The home health nurse visits an elderly female client who had a brain attack three months
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b ago and is now able to ambulate with the assistance of the quad cane. Which assessment
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b finding has the greatest implications for this clients care? - answer-The nurse notes that
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b there are numerous scatter rugs throughout the house. Scatter rugs pose a safety hazard
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b because the client can trip on them when ambulating, so this finding has the greatest
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b significance in planning this client's care b b b b b
The nurse is digitally removing a fecal impaction for a client. The nurse should stop the
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b procedure and take corrective action if which client reaction is noted? - answer-Pulse rate
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b decreases from 78 to 52 beats/min. b b b b b
Parasympathetic reactions can occur as a result of digital stimulation of the anal sphincter,
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b which should be stopped if the client experiences a vagal response, such as bradycardia
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The nurse is providing passive range of motion exercises to the hip and knee for a client
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b who is unconscious. After supporting the client's knee with one hand, what action should
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b the nurse take next? - answer-Cradle the client's heel.
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, Passive ROM exercise for the hip and knee is provided by supporting the joints of the knee
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b and ankle and gently moving the limb in a slow, smooth, firm but gentle manner, followed
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b by bending the knee and moving it toward the chest as far as it will go. Bed should be
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b raised to a comfortable working level first
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A client who has moderate, persistent, chronic neuropathic pain due to diabetic
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b neuropathy takes gabapentin (neurontin) and ibuprofen daily. If step 2 of the WHO pain
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b relief ladder is prescribed, which drug protocol should be implemented? - answer-
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Continue gabapentin b
*step 1 drugs are nonopioid analgesics
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*step 2 and 3 are narcotics and should be given around the clock rather than by the
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b clients PRN requests b b
The nurse is preparing to irrigate a client's indwelling urinary catheter using an open
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b technique. What action should the nurse take after applying gloves? - answer-Draw up the
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b irrigating solution into the syringe.b b b b
To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw
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b up the irrigating solution into the syringe. The syringe is then attached to the catheter
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b and the fluid instilled, using aseptic technique. Once the irrigating solution is instilled, the
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b client's catheter should be secured to the drainage tubing. The urinary drainage bag can
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