HESI Fundamentals Practice Exam In assisting an older adult client prepare to take a tub bath, which nursing action is most important?(Ans- Check the bath water temperature.
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection?(Ans- 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?(Ans- 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?(Ans- Daily black, sticky stool
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?(Ans- "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 1 / 2
count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate should the nurse document?(Ans- 16
Which action should the nurse implement when providing wound care instructions to a client who does not speak English?(Ans- 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?(Ans- Compare the current reading with the client's previously documented blood pressure readings.
When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety?(Ans- 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?(Ans- 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?(Ans- The UAP auscultates the popliteal pulse with the cuff on the lower leg.
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