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HESI Test Bank-Fundamentals Completely Answered
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HESI Test Bank-Fundamentals Completely Answered The home health nurse visits an elderly female client who had a brain attack three months ago and is now able to ambulate with the assistance of the quad cane. Which assessment finding has the greatest implications for this clients care? The nur...

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  • 13 september 2023
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  • 2023/2024
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Voorbeeld van de inhoud

HESI Test Bank-Fundamentals
Completely Answered

The home health nurse visits an elderly female client who had a brain attack three months ago and is
now able to ambulate with the assistance of the quad cane. Which assessment finding has the
greatest implications for this clients care?

The nurse notes that there are numerous scatter rugs throughout the house. Scatter rugs pose a safety
hazard because the client can trip on them when ambulating, so this finding has the greatest significance
in planning this client's care

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?

Pulse rate decreases from 78 to 52 beats/min.

Parasympathetic reactions can occur as a result of digital stimulation of the anal sphincter, which should
be stopped if the client experiences a vagal response, such as bradycardia

The nurse is providing passive range of motion exercises to the hip and knee for a client who is
unconscious. After supporting the client's knee with one hand, what action should the nurse take
next?

Cradle the client's heel.

Passive ROM exercise for the hip and knee is provided by supporting the joints of the knee and ankle
and gently moving the limb in a slow, smooth, firm but gentle manner, followed by bending the knee
and moving it toward the chest as far as it will go. Bed should be raised to a comfortable working level
first

A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes
gabapentin (neurontin) and ibuprofen daily. If step 2 of the WHO pain relief ladder is prescribed,
which drug protocol should be implemented?

Continue gabapentin

*step 1 drugs are nonopioid analgesics
*step 2 and 3 are narcotics and should be given around the clock rather than by the clients PRN requests

The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What
action should the nurse take after applying gloves?

Draw up the irrigating solution into the syringe.

, To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the irrigating
solution into the syringe. The syringe is then attached to the catheter and the fluid instilled, using
aseptic technique. Once the irrigating solution is instilled, the client's catheter should be secured to the
drainage tubing. The urinary drainage bag can be emptied whenever intake and output measurement is
indicated, and the instilled irrigating fluid can be subtracted from the output at that time.

Which client care requires the nurse to wear barrier gloves as required by the protocol for standard
precautions?

Emptying the urinary catheter drainage bag for a client with Alzheimer's disease

*possible contact with body secretions, excretions, or broken skin is an indication for wearing barrier
gloves. Emptying a urine drainage bag requires the use of gloves.

What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is
immobile?

Position prone with a small pillow below the diaphragm

*this maintains alignment and provides the best pressure relief over the sacral bony prominence

What intervention should the nurse include in the plan of care for a client who is being treated with
an Unna's paste boot for leg ulcers due to chronic venous insufficiency?

Check capillary refill of toes on lower extremity with Unna's paste boot

*it becomes rigid after it dries so it is important to check distally for adequate circulation

The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous
access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm
on the infusion pump indicates an obstruction. What action should the nurse take first?

Reposition the client's arm.

If the client's elbow is bent, the IV may be unable to infuse, resulting in an obstruction alarm, so the
nurse should first attempt to reposition the client's arm to alleviate any obstruction.

A female client who has breast cancer with metastasis to the liver and spine is admitted with
constant, severe pain despite around-the-clock use of oxycodone and amitriptyline for pain control at
home. During the admission assessment, which information is most important for the nurse to
obtain?

Sensory pain, area, intensity, and nature of the pain.

PAIN components should be assessed in every pain assessment and are essential in identifying
appropriate therapy for the client's specific type and severity of pain, which may indicate the onset of
disease progression or complications.

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