Funds HESI
2023/2024
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 a quad cane. Which assessment finding has the greatest implications for this client's care?a.) The husband, who is the caregiver, begins to weep when the nurse asks how he is doing.b.) The client tells the nurse that she does not have much of an appetite today.c.) The nurse notes that there are numerous scatter rugs throughout the house.
- ) The client's pulse rate is 10 beats higher than it was at the last visit one week
ago. - ANSWER C 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?a.) Temperature increases from 98.8° to 99.0° F.b.) Pulse rate decreases from 78 to 52 beats/min.c.) Respiratory rate increases from 16 to 24 breaths/min.d.) Blood pressure increases from 110/84 to 118/88 mm/Hg - ANSWER
B 1 / 3
The nurse is providing passive range of motion (ROM) 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?a.) Raise the bed to a comfortable working level.b.) Bend the client's knee.c.) Move the knee toward the chest as far as it will go.d.) Cradle the client's heel. - ANSWER D A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented?a.) Continue gabapentin.b.) Discontinue ibuprofen.c.) Add aspirin to the protocol.d.) Add oral methadone to the protocol. - ANSWER
A 2 / 3
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?a.) Empty the client's urinary drainage bag.b.) Draw up the irrigating solution into the syringe.c.) Secure the client's catheter to the drainage tubing.d.) Use aseptic technique to instill the irrigating solution. - ANSWER B Which client care requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions?• Removing the empty food tray from a client with a urinary catheter.• Washing and combing the hair of a client with a fractured leg in traction.• Administering oral medications to a cooperative client with a wound infection.• Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.
- ANSWER D
What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile?• Maintain in a lateral position using protective wrist and vest devices.• Position prone with a small pillow below the diaphragm.• Raise the head and knee gatch when lying in a supine position.
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