Hesi Fundamentals

Fundamentals Hesi

1. The home health nurse visits an elderly female client who had a brain attack three months

ago and is now able to ambulate with theassistance of a quad cane. Which assessment finding

has the greatest implications for this client's care?

• The husband, who is the caregiver, begins to weep when the nurseasks how he is doing.

• The client tells the nurse that she does not have much of anappetite today.

• The nurse notes that there are numerous scatter rugsthroughout the

house. Correct

• The client's pulse rate is 10 beats higher than it was at the lastvisit one week ago.

Scatter rugs (C) pose a safety hazard because the client can trip on them when ambulating, so

this finding has the greatest significance in planning this client's care. Psychological support

of the caregiver

(A) is a less acute need than that of client safety. The nurse needs toobtain more information

about (B), but this is not a safety issue. (D) is not a significant increase, and additional

assessment might provide information about the reason for the increase (anxiety, exercise, etc.).

2. The nurse is digitally removing a fecal impaction for a client. The nurse should stop the

procedure and take corrective action if whichclient reaction is noted?

• Temperature increases from 98.8° to 99.0° F.

• Pulse rate decreases from 78 to 52 beats/min. Correct

• Respiratory rate increases from 16 to 24 breaths/min.

• Blood pressure increases from 110/84 to 118/88 mm/Hg. Parasympathetic reaction can occur

as a result of digital stimulation of the anal sphincter, which should be stopped if the client

experiences a vagal response, such as bradycardia (B). (A, C, and D)do not warrant stopping

the procedure.

3. The nurse is providing passive range of motion (ROM) exercises tothe 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?

• Raise the bed to a comfortable working level.

• Bend the client's knee.

• Move the knee toward the chest as far as it will go.

• Cradle the client's heel. Correct

Passive ROM exercise for the hip and knee is provided by supportingthe joints of the knee

and ankle (D) and gently moving the limb in a slow, smooth, firm but gentle manner. (A)

should be done before theexercises are begun to prevent injury to the nurse and client. (B) is

carried out after both joints are supported. After the knee is bent, then the knee is moved toward

the chest to the point of resistance

(C) two or three times.

4. A client who has moderate, persistent, chronic neuropathic paindue 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?

• Continue gabapentin. Correct

• Discontinue ibuprofen.

• Add aspirin to the protocol.

• Add oral methadone to the protocol.

Based on the WHO pain relief ladder, adjunct medications, such as gabapentin (Neurontin), an

antiseizure medication, may be used atany step for anxiety and pain management, so (A)

should be implemented. Nonopiod analgesics, such as ibuprofen (A) and aspirin (C) are

Step 1 drugs. Step 2 and 3 include opioid narcotics (D), and to maintain freedom from pain,

drugs should be given around the clock rather than by the clients PRN requests.

5. The nurse is preparing to irrigate a client's indwelling urinary catheter using an open

technique. What action should the nursetake after applying gloves?

• Empty the client's urinary drainage bag.

• Draw up the irrigating solution into the syringe. Correct

• Secure the client's catheter to the drainage tubing.

• Use aseptic technique to instill the irrigating solution.

To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up

the irrigating solution into the syringe (B). The syringe is then attached to the catheter and the

fluid instilled, using aseptic technique (D). Once the irrigating solution isinstilled, the client's

catheter should be secured to the drainage