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HESI 225 Quiz Questions and Complete Solutions Graded A+
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HESI 225 Quiz Questions and Complete Solutions Graded A+
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HESI 225 Quiz Questions and CompleteSolutions Graded A+
A female client asks the nurse to find someone who can translate her treatment concerns into her native
language. Which action should the nurse take?
Explain that anyone who speaks her language can answer her questions.
Provide a translator only in an emergency situation.
Ask a family member or friend of the client to translate.
Request and document the name of the certified translator. - Answer: Request and document the name
of the certified translator.
A certified translator should be requested to ensure the exchanged information is reliable and
unaltered. To adhere to legal requirements in some states, the name of the translator should be
documented. Client information that is translated is private and protected under HIPAA rules, so
enaging anyone as a translator is not the best action. Family members are not preferred translators as
they may skew information and not translate the exact information.
The nurse witnesses the signature of a client who has signed an informed consent. Which statement
best explains this nursing responsibility?
The client voluntarily signed the form.
The client fully understands the procedure.
The client agrees with the procedure to be done.
The client authorizes continued treatment. - Answer: The client voluntarily signed the form.
,The nurse signs the consent form to witness that the client voluntarily signs the consent, that the client's
signature is authentic, and that the client is otherwise competent to give consent. It is the healthcare
provider's responsibility to ensure that the client fully understands the procedure. The nurse's signature
does not indicate that the client agrees to or authorizes treatment.
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse
have for planning care in terms of the client's beliefs?
Autopsy of the body is prohibited.
Blood transfusions are forbidden.
Alcohol use in any form is not allowed.
A vegetarian diet must be followed. - Answer: Blood transfusions are forbidden.
Blood transfusions are forbidden in the Jehovah's Witness religion. Judaism prohibits autopsies and
Buddhism forbids the use of alcohol and drugs. Many of these sects follow a vegetarian diet, but the
direct impact on nursing care concerns beliefs about transfusions.
A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the
nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation
should the nurse enter in the client's medical record?
Healthcare provider notified of failure to collect specimens for prescribed blood studies.
Blood specimens not collected because client no longer wants blood tests performed.
Healthcare provider notified of client's refusal to have blood specimens collected for testing.
,Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified. -
Answer: Healthcare provider notified of client's refusal to have blood specimens collected for testing.
When a client refuses a treatment, the exact words of the client regarding the client's refusal of care
should be documented in a narrative format. The nurse should not editorialize, make judgments, or
document assumptions about the client's wishes.
A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse
assesses that there has been no drainage through the nasogastric tube in the last two hours. Which
action should the nurse take first?
Irrigate the nasogastric tube with sterile normal saline.
Reposition the client on her side.
Advance the nasogastric tube an additional five centimeters.
Administer an intravenous antiemetic prescribed for PRN use. - Answer: Reposition the client on her
side.
The nurse has identified two things suggesting the the nasogastric tube is not functioning properly; the
client is nauseated and no drainage from the tube in 2 hours. The immediate priority is to determine if
the tube is functioning correctly, which would then relieve the client's nausea. The least invasive
intervention should be attempted first. This includes repositioning the client to her side. The tube may
need to be irrigated or advanced but these actions should follow repositioning the client.
Which assessment data provides the most accurate determination of proper placement of a nasogastric
tube?
Aspirating gastric contents to assure a pH value of 4 or less.
Hearing air pass in the stomach after injecting air into the tubing.
, Examining a chest x-ray obtained after the tubing was inserted.
Checking the remaining length of tubing to ensure that the correct length was inserted. - Answer:
Examining a chest x-ray obtained after the tubing was inserted.
Assessing the pH of gastric contents and listening for air in the stomach are both methods used to
determine proper placement of the nasogatric tube. However, the best indicator that the tube is
properly placed is confirming with a chest x-ray.
An older client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus
enteral feedings through a gastrostomy tube (GT). What is the best position for the client for
administration of the bolus tube feedings?
Prone.
Fowler's.
Sims'.
Supine. - Answer: Fowler's.
A gastrostomy tube (GT), known as a PEG tube, due to placement by a percutaneous endoscopic
gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for
long-term administration of nutrition and hydration in the debilitated client. The unresponsive client
should be positioned in a semi-sitting (Fowler's) position during feeding through a gastrostomy tube to
decrease the occurrence of aspiration. In prone or Sims' positions, the client is placed on the abdomen,
an unsafe position for feeding. Placing the client in supine position increases the risk of aspiration.
Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels
warm enough. What is the best response by the nurse?
"That means you have derived the maximum benefit, and the heat can be removed."
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