Hesirn - Study guides, Class notes & Summaries

1. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child? A) Make certain the child is maintained in correct body alignment. B) Be sure the traction weights touch the end of the bed. C) Adjust the head and foot of the bed for the child's comfort D) Release the traction for 15-20 minutes every 6 hours PRN. The correct answer is A: Make certain the child is maintained in correct body alignment. 2. The nurse is a...

• Thenurseiscaringforaclientinatrialfibrillation.Theatrialheartrateis250and the ventricular rate is controlled at 75. Which of the following findings iscausefor the mostconcern? A) Diminishedbowelsounds B) Lossofappetite C) Acold,palelower leg D) Tachypnea - A-Fibcancausefluidbuildupinthelowerextremities.Itcausesbloodtopoolupintheatria. • Theclientwithinfectiveendocarditismustbeassessedfrequentlybythehome health nurse. Which finding suggests that antibiotic therapy is noteffecti...

• After an explosion at a factory one of the workers approaches the nurse and says “I am an unlicensed assistive personnel (UAP) at the local hospital.” Which of these tasks should the nurse assign to this worker who wants to help during the care of the wounded workers? A) Get temperatures B) Take blood pressure C) Palpate pulses D) Check alertness • Which of these clients would the nurse recommend to keep in the hospital during an internal disaster at the agency? A) An a...

A nurse in a mental health clinic is planning care for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority? A) Advise the client to take frequent sips of water. B) Instruct the client to avoid driving during initial therapy. C) Consult a dietitian for a calorie-controlled diet plan. D) Recommend that the client exercise regularly. Answer: B - The greatest risk to this client is injury resulting from drows...

• A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication? A) "I cannot give this medication as it is written. I have no idea of what you mean." B) "Would you please clarify what you have written so I am sure I am reading it correctly?" C) "I am having difficulty reading your handwriting. It would save me time if you would be more careful." D) "Please print in the future so I do not have to spend extra time attempti...

• A client has returned from a cardiac catheterization. Which one of the followingassessmentswouldindicatetheclientisexperiencingacomplicationfromtheprocedure? A) Increasedbloodpressure B) Increasedheartrate C) Lossofpulseintheextremity D) Decreasedurineoutput ThecorrectanswerisC: Lossofpulsein theextremity • Anursechecksaclientwhoisonavolume-cycledventilator.Whichfindingindicatesthattheclientmayneedsuctioning? A) drowsiness B) complaintofnausea C) pulserateof92D)restlessness The...

An oriented patient has recently had surgery. Which action is best for the nurse to take to assess this patient’s pain? a. Assess the patient’s body language. b. Ask the patient to rate the level of pain. c. Observe the cardiac monitor for increased heart rate. d. Have the patient describe the effect of pain on the ability to cope. .A nurse is caring for a patient who recently had abdominal surgery and is experiencing severe pain. The patient’s blood pressure is 110/60 mm Hg, an...

1. Following discharge teaching, a maleclient with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse? a. Remind theclient that it is also important toswitch todecaffeinated coffee and tea. b. Suggest that the client also plan to eat frequent small meals to reduce discomfort d. Reinforce this teaching by asking theclient to list a dairy food that hemight select. 2. A m...

1. The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. Which action should the nurse take? a. Turn on the television. b. Explain the procedure. c. Tell the patient “Close your eyes.” d. Ask the family to leave the room. ANS: B Explaining the procedure educates the patient regarding the dressing change and involves him in the care, thereby allowing the patient some control in decreasing anxiety. Telling the...

HESI RN Fundamentals v1 and v2 HESI RN Fundamentals v1 and v2 HESI RN Fundamentals v1 and v2