HESI Fundamentals Practice Exam In assisting an older adult client prepare to take a tub bath, which nursing action is most important? - ANSWER Check the bath water temperature.By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection? - ANSWER Mode of transmission The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction? - ANSWER Perform range-of-motion exercises to prevent contractures.In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible? - ANSWER Daily black, sticky stool 1 / 3
While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse? - ANSWER "How will this affect your present sexual activity?" The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate should the nurse document? - ANSWER 16 Which action should the nurse implement when providing wound care instructions to a client who does not speak English? - ANSWER Speak directly to the client, with an interpreter translating.A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first? - ANSWER Compare the current reading with the client's previously documented blood pressure readings. 2 / 3
When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety? - ANSWER Put bed rails up on the side of bed opposite from the nurse.Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? - ANSWER Sodium The nurse observes a UAP taking a client's blood pressure in the lower extremity.Which observation of this procedure requires the nurse's intervention? - ANSWER The UAP auscultates the popliteal pulse with the cuff on the lower leg.After the nurse tells an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all health care providers and nurses. How should the nurse respond? - ANSWER Calmly reassure the client that the discomfort will be temporary.The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action
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