BSN 225 - HESI FUNDAMENTALS EXAM QUESTIONS WITH COMPLETE SOLUTIONS
The nurse is caring for a client on hospice who was started on a 25 mcg/hr Fentanyl patch yesterday at 0800. The nurse completes an assessment today at 2000 and reviews the following assessment data:
Yesterday 0800
BP 98/60
HR...
BSN 225 - HESI FUNDAMENTALS EXAM QUESTIONS WITH COMPLETE SOLUTIONS
The nurse is caring for a client on hospice who was started on a 25 mcg/hr Fentanyl patch yesterday at 0800. The nurse completes an assessment today at 2000 and reviews the following assessment data:
Yesterday 0800 BP 98/60 HR 110 RR 24 O2SAT 94%
PAIN 6/10
INTERVENTIONS
Fentanyl patch 25mcg/hr applied Yesterday 2000
100/55
100
20
95%
2/10
Reposition, visiting with family
Today 0800
92/40
104
24
92%
4/10
Ice pack applied
Today 2000
100/65
110
24
94%
7/10
Which intervention is best for the nurse to provide? a. explain that the fentanyl patch takes time to become effective, and they should experience relief soon.
b. offer to administer 5mg of morphine orally as prescribed for breakthrough pain
c. reposition the client and offer to give a back rub.
d. call the provider to provide an update on the client's condition - answer b. offer to administer 5mg of morphine orally as prescribed for breakthrough pain
Rationale:
A fentanyl patch is effective for 72 hours before it needs to be replaced. This breakthrough pain is evidenced by a decline in pain rating followed by an elevated pain rating during the time that the fentanyl patch should still be effective.
When changing a client's post-op wound dressing, the nurse notes yellow purulent drainage. What action should the nurse take?
a. Notify the healthcare provider.
b. Cover the wound with clean gauze and secure.
c. Irrigate the wound with sterile water and leave open to air.
d. Irrigate the wound with normal saline and pack with gauze. - answer a. Notify the healthcare provider.
Rationale:
Yellow purulent drainage is an indication of an infection. This finding should be reported to the healthcare provider for assessment and intervention.
Choices B, C, and D are all incorrect because the priority action is to notify the healthcare provider of the status of the wound. Further wound management (cultures, irrigation, or no irrigation, packing or no packing, antibiotics, etc.) should be determined after assessment of the site by the surgical team. Irrigating the wound before assessment has been completed may interfere with medical decision-making and hsould be avoided.
The healthcare provider prescribes enteral feeds of Jevity 1.2 cal at 66mL/hour over 20 hours, and free water flushes of 225 mL q 4 hours x 24 hr via nasogastric tube. How many mL of total fluid will the client receive in 24 hours? (Enter numerical value only. If rounding is required, round to one decimal place.) - answer 2670 mL
Rationale:
66mL/hour x 20 hours = 1320 mL
Then it is necessary to calculate the amount of fluid from the free water flushes.
Free water flushes every 4 hours for 24 hours = 6 flushes
225 mL x 65 flushes = 1350 mL Finally, add the two sums together: 1320 mL + 1350 mL = 2670 mL in 24 hours
The nurse prepares to administer a medication that comes in tablet for through a client's
gastrostomy tube. Which actions should the nurse implement? (Select all that apply)
a. Position client in Fowler's position
b. Aspirate gastric contents at the start and end of the procedure
c. Mix crushed medication with tube feeding
d. Pour dissolved medication into a syringe and inject into G tube
e. Flush tube with 30 cc of lukewarm water prior and after the medication administration - answer a. Position client in Fowler's position
e. Flush tube with 30 cc of lukewarm water prior to and after the medication administration
Rationale:
Choices A and E describe the correct execution of the listed steps of medication administration. Fowler's position promotes the downward flow of the medication into the stomach and decreases the risk for medication reflux and aspiration. The client should be maintained in Fowler's position during the procedure and for 30 minutes after the medication administration. The tube should be flushed before and after the medication administration to clean the tubing and prevent blockage. Lukewarm water (room temperature) should be used to prevent abdominal cramping. To prevent volume overload, no more than 30 ml should be administered per flush. The nurse should follow a specific protocol to promote client safety and medication efficacy when providing medication using a G-tube. The appropriate steps include:
1. positioning the client in Fowler's position
2. verifying tube placement and GI function through aspiration of stomach contents
3. flushing the tube with water prior to medication administration
4. preparing the medication by crushing and dissolving it into water
5. allowing the solution to drain into the G-tube by gravity
6. flushing the tube with water after the medication administration
7. reclamping the tube after the administration is completed and the tube has been flushed.
The nurse notes that a client who is receiving oxygen by nasal cannula continues to remove the oxygen prongs from the nares. What action should the nurse take?
a. tape the oxygen tubing to the client's nares
b. assess why the client removes the nasal cannula
c. increase the oxygen flow rate
d. change the nasal cannula to a mask - answer b. assess why the client removes the nasal cannula
Rationale:
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