HESI Fundamentals Practice Exam 1 A 35y/o client with cancer refuses to allow a nurse to insert an IV for scheduled chemo & states that she's ready to go home to die. What intervention should the nurse initiate? - CORRECT ANSWER Evaluate the client's mental status for competence to refuse treatment
Rationale: Competent clients have the right to refuse treatment. The nurse
cannot document until the HCP is notified of the patient's wishes & a d/c RX is obtained. Advance directives & DNR are not necessary for competent client to refuse care.A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates client's protein status for the longest length of time? - CORRECT ANSWER Serum albumin Rationale: Serum albumin has a long half-life. 1 / 3
What client statement indicates to the nurse that the client requires assistance with bathing? - CORRECT ANSWER "I don't understand why I'm so weak & tired." How should the nurse handle linens that are soiled with incontinent feces? - CORRECT ANSWER Place the soiled linens in a pillow case & deposit them in the dirty linen hamper When caring for an immobile client, what nursing diagnosis has the highest priority? - CORRECT ANSWER Impaired gas exchange The nurse assesses an immobile, elderly male client & determines that his blood pressure is 138/60, his temperature is 95.8F & his output is 100 mL of concentrated urine during the last hour. He has wet sounding lungs & increased respiratory secretions. Based on these assessment findings , what nursing action is most important for the nurse to implement? - CORRECT ANSWER Turn the client q2h Rationale: It will help move & drain respiratory secretions & prevent pneumonia from occurring. 2 / 3
The home health nurse visits an elderly female client who had a brain attack 3 months ago & is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care? - CORRECT ANSWER The nurse notes there are numerous scatter rugs throughout the house The nurse removes the dressing on a client's heel that is cover a pressure sore 1" in diameter & finds that there is straw-colored drainage seeping from the wound.What description of this finding should the nurse include in the client's record? - CORRECT ANSWER One-inch pressure sore draining serous fluid Medication is prescribed to be given QID. What schedule should the nurse use to administer this Rx? - CORRECT ANSWER 0800, 1200, 1600, 2000 The nurse working in the ED is assessing 4 clients' ability to tolerate pain. Which client is likely to tolerate a higher level of pain? - CORRECT ANSWER 1 55y/o woman who has had moderate low back pain for 3 months
Rationale: Experiences with the same type of pain that has successfully been
relieved makes it easier for the client to interpret the pain sensation and, as a result, the client is better prepared to take steps to relieve the pain. All other clients are having new experiences with pain.
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