HESI Practice Test Questions Full Solved 100 % 2024.

While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement? - Answer Instruct the client to take slow deep breaths and stop bearing down. The nurse assesses an immobile, elderly male client and determines that his blood pressure is 138/60, his temperature is 95.8 F, and his output is 100 ml of concentrated urine during the last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, what nursing action is most important for the nurse to implement? - Answer Turn the client q2h. The home health nurse visits an elderly female client who had a stroke three months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care? - Answer The nurse notes that there are numerous scatter rugs throughout the house. In providing care for a terminally ill resident of a long-term care facility, the nurse determines that the resident is exhibiting signs of impending death and has a "do not resuscitate" or DNR status. What intervention should the nurse implement first? - Answer Notify family members of the client's condition. A healthcare provider is performing a sterile procedure at a client's bedside. Near the end of the procedure, the nurse observes the healthcare provider contaminate a sterile glove and the sterile field. What is the best action for the nurse to implement? - Answer Identify the break in surgical asepsis and provide another set of sterile supplies. The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted? - Answer Pulse rate decreases from 78 to 52 beats/min. Which client care activity requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions? - Answer Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.