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CASAL 1/ Hesi Remediation: Questions With Solutions
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CASAL 1/ Hesi Remediation: Questions With Solutions
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CASAL 1/ Hesi Remediation: Questions With SolutionsAn adult client has vomiting, diarrhea, dry mucous membranes, skin tenting,
and delayed capillary refill. The client's vital signs are: HR 110, sitting BP
104/72 that drops to 84/62 when the client stands up. The client's laboratory
results include: BUN 24 mg/dl and urine specific gravity 1.032. Which
conditions should the nurse consider in planning care for this client? Right
Ans - *Extracellular fluid volume deficit..
Urinary retention.
*Postural hypotension.
Cardiac output impairment.
*Impaired tissue perfusion.
Rationale:
The nursing assessment indicates a fluid deficit. Skin tenting, postural
hypotension, hemoconcentration noted in labs, and impaired tissue perfusion
all indicate fluid volume deficit
The UAP is assisting a client getting into the shower. The charge nurse
answers a call from the cast clinic to immediately send the UAP's other
assigned client to the clinic. Which action should the nurse take? Right Ans
- Ask the UAP to find another team member to take the client to the clinic.
*Notify the delegating nurse of the current request from the cast clinic.
Instruct the UAP to take the client to clinic after helping the other client taking
a shower.
While the client is showering the UAP should take the other client to cast
clinic.
Rationale:
The charge nurse should notify the delegating nurse of the situation. The third
principle of delegation is "The person to whom the assignment was delegated
cannot delegate that assignment to someone else... the delegating nurse needs
to be notified and reassign the task..."
What is the best description of evidence-based practice (EBP) in nursing?
Right Ans - Nurses measure the effects of interventions on populations to
determine individual client care.
, *Nurses implement interventions which have already been determined to be
safe and effective in clinical practice.
Nurses generate answers to questions about interventions not already used in
the care of clients.
Nurses exchange traditional interventions and established clinical nursing
practice for alternative, non-traditional approaches.
Rationale:
The focus of evidence-based practice is the use of interventions that have
already been determined to be safe and effective in clinical practice
When applying restraints, which action is most important for the nurse to take
to prevent contractures? Right Ans - Pad skin and any bony prominences
that will be covered by the restraint.
*Correct anatomical positioning where restraint is applied and is restricting
movement.
Assess the neurovascular status of the area which is restrained or has
movement restrictied.
Inspect the area where restraint is to be placed, ensuring there are no tubing
or devices present.
Rationale:
Correct anatomical positioning where the restraint is to be applied and
restricting movement will help prevent contractures. Other options are
important but do not directly address prevention of contractures.
The nurse is updating unit policies and procedures. Which source provides
the strongest evidence for practice changes? Right Ans - Randomized
controlled trials and blinded studies.
Practice guidelines and standards of care.
Expert consensus and collaborative opinion.
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