HESI FUNDAMENTALS STUDY GUIDE 57 TERMS AND
EXPLANITION 2022/2023
Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? - correct answer Sodium
Rationale:
Monitoring serum sodium levels (D) for hyponatremia is indicated during prolonged NG suctioning because of loss of fluids.When assisting a client from the bed to a chair, which procedure is best for the nurse to follow? - correct answer With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair.
Rationale:
(B) describes the correct positioning of the nurse and affords the nurse a wide base of support while stabilizing the client's knees when assisting to a standing position. The chair should be placed at a 45- degree angle to the bed, with the back of the chair toward the head of the bed The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next? - correct answer Check for kinks in the tubing and raise the IV pole.
Rationale:
The nurse should first check the tubing and height of the bag on the IV pole (B), which are common factors that may slow the rate. Gravity infusion rates are influenced by the height of the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity, client blood pressure (crying in the pediatric client), and infiltration.The nurse is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery? - correct answer Taking anticoagulants for the past year.
Rationale:
Anticoagulants (B) increase the risk for bleeding during surgery, which can pose a threat for the development of surgical complications. The health care provider should be informed that the client is taking these drugs. 1 / 4
The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order? - correct answer "This is a new pill I have never taken before."
Rationale:
The client's recognition of a "new" pill requires further assessment (D) to verify that the medication is correct, if it is a new prescription or a different manufacturer, or if the client needs further instruction.Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply.)
A.Place the client in a side-lying position.
B.Pull the auricle upward and outward.
C.Hold the dropper 6 cm above the ear canal.
D.Place a cotton ball into the inner canal.
E.Pull the auricle down and back - correct answer Rationale: 2 / 4
The correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D).The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E).A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide?A.Decrease intake of fluids after the evening meal.
B.Drink a glass of cranberry juice every day.
C.Drink a glass of warm decaffeinated beverage at bedtime.
D.Consult the health care provider about a sleeping pill. - correct answer Rationale: Nocturia is urination during the night. (A) is helpful to decrease the production of urine, thus decreasing the need to void at night. (B) helps prevent bladder infections. (C) may promote sleep, but the fluid will contribute to nocturia. (D) may result in urinary incontinence if the client is sedated and does not awaken to void.The nurse teaches the use of a gait belt to a male caregiver whose wife has right-sided weakness and needs assistance with ambulation. The caregiver performs a return demonstration of the skill. Which observation indicates that the caregiver has learned how to perform this procedure correctly?Standing on his wife's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed.
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B.Standing on his wife's weak side, the caregiver provides security by holding the gait belt from the back.
C.Standing behind his wife, the caregiver provides balance by holding both sides of the gait belt.
D.Standing slightly in front and to the right of his wife, the caregiver guides her forward by gently pulling
on the gait belt. - correct answer Rationale:
His wife is most likely to lean toward the weak side and needs extra support on that side and from the back (B) to prevent falling. (A, C, and D) provide less security for her.A female nurse is assigned to care for a close friend, who says, "I am worried that friends will find out about my diagnosis." The nurse tells her friend that legally she must protect a client's confidentiality.Which resource describes the nurse's legal responsibilities?A.Code of Ethics for Nurses
B.State Nurse Practice Act
C.Patient's Bill of Rights
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