1. An elderly client with a fractured D. Gently lift the client when moving into
left hip is on strict bedrest. Which a desired position.
nursing measure is essential to
the client's nursing care?
A. Massage any reddened areas Rationale:
for at least five minutes. To avoid shearing forces when reposi-
tioning, the client should be lifted gently
B. Encourage active range of mo- across a surface (D). Reddened areas
tion exercises on extremities. should not be massaged (A) since this
may increase the damage to already
C. Position the client laterally, traumatized skin. To control pain and
prone, and dorsally in sequence. muscle spasms, active range of motion
(B) may be limited on the affected leg.
D. Gently lift the client when mov- The position described in (C) is con-
ing into a desired position. traindicated for a client with a fractured
left hip.
2. The nurse is administering med- B. Flush the tube with water.
ications through a nasogastric
tube (NGT) which is connected
to suction. After ensuring cor-
rect tube placement, what action Rationale:
should the nurse take next? The NGT should be flushed before, af-
ter and in between each medication
A. Clamp the tube for 20 minutes. administered (B). Once all medications
are administered, the NGT should be
B. Flush the tube with water. clamped for 20 minutes (A). (C and D)
may be implemented only after the tub-
C. Administer the medications as ing has been flushed.
prescribed.
D. Crush the tablets and dissolve
in sterile water.
3. A client who is in hospice care A. Give an around-the-clock schedule
complains of increasing amounts for administration of analgesics.
of pain. The healthcare provider
prescribes an analgesic every
, HESI PN Fundamentals ashstvns
four hours as needed. Which ac-
tion should the nurse implement? Rationale:
The most effective management of pain
A. Give an around-the-clock is achieved using an around-the-clock
schedule for administration of schedule that provides analgesic med-
analgesics. ications on a regular basis (A) and in
a timely manner. Analgesics are less
B. Administer analgesic medica- effective if pain persists until it is severe,
tion as needed when the pain is so an analgesic medication should be
severe. administered before the client's pain
peaks (B). Providing comfort is a priority
C. Provide medication to keep the for the client who is dying, but sedation
client sedated and unaware of that impairs the client's ability to inter-
stimuli. act and experience the time before life
ends should be minimized (C). Offer-
D. Offer a medication-free period ing a medication-free period allows the
so that the client can do daily ac- serum drug level to fall, which is not
tivities. an effective method to manage chronic
pain (D).
4. When assessing a client with A. Loosen the right wrist restraint.
wrist restraints, the nurse ob-
serves that the fingers on the
right hand are blue. What action
should the nurse implement first? Rationale:
The priority nursing action is to restore
A. Loosen the right wrist restraint. circulation by loosening the restraint
(A), because blue fingers (cyanosis) in-
B. Apply a pulse oximeter to the dicates decreased circulation. (C and
right hand. D) are also important nursing interven-
tions, but do not have the priority of
C. Compare hand color bilaterally. (A). Pulse oximetry (B) measures the
saturation of hemoglobin with oxygen
D. Palpate the right radial pulse. and is not indicated in situations where
the cyanosis is related to mechanical
compression (the restraints).
5.
, HESI PN Fundamentals ashstvns
The nurse is assessing the nu- B. A lactating woman nursing her
tritional status of several clients. 3-day-old infant.
Which client has the greatest nu-
tritional need for additional intake
of protein?
Rationale:
A. A college-age track runner with A lactating woman (B) has the greatest
a sprained ankle. need for additional protein intake. (A, C,
and D) are all conditions that require
B. A lactating woman nursing her protein, but do not have the increased
3-day-old infant. metabolic protein demands of lactation.
C. A school-aged child with Type
2 diabetes.
D. An elderly man being treated
for a peptic ulcer.
6. A client is in the radiology depart- D. Give the missed dose at 1300 and
ment at 0900 when the prescrip- change the schedule to administer daily
tion levofloxacin (Levaquin) 500 at 1300.
mg IV q24h is scheduled to be ad-
ministered. The client returns to
the unit at 1300. What is the best
intervention for the nurse to im- Rationale:
plement? To ensure that a therapeutic level of
medication is maintained, the nurse
A. Contact the healthcare should administer the missed dose as
provider and complete a medica- soon as possible, and revise the admin-
tion variance form. istration schedule accordingly to pre-
vent dangerously increasing the level of
B. Administer the Levaquin at the medication in the bloodstream (D).
1300 and resume the 0900 sched- The nurse should document the reason
ule in the morning. for the late dose, but (A and C) are not
warranted. (B) could result in increased
C. Notify the charge nurse and blood levels of the drug.
complete an incident report to ex-
plain the missed dose.
, HESI PN Fundamentals ashstvns
D. Give the missed dose at 1300
and change the schedule to ad-
minister daily at 1300.
7. While instructing a male client's A. Acknowledge that she is supporting
wife in the performance of pas- the arm correctly.
sive range-of-motion exercises
to his contracted shoulder, the
nurse observes that she is hold-
ing his arm above and below Rationale:
the elbow. What nursing action The wife is performing the passive ROM
should the nurse implement? correctly, therefore the nurse should ac-
knowledge this fact (A). The joint that
A. Acknowledge that she is sup- is being exercised should be uncovered
porting the arm correctly. (B) while the rest of the body should
remain covered for warmth and priva-
B. Encourage her to keep the joint cy. (C and D) do not provide adequate
covered to maintain warmth. support to the joint while still allowing
for joint movement.
C. Reinforce the need to grip di-
rectly under the joint for better
support.
D. Instruct her to grip directly over
the joint for better motion.
8. What is the most important rea- B. A decreased flow rate could result in
son for starting intravenous in- the formation of a thrombosis.
fusions in the upper extremities
rather than the lower extremities
of adults?
Rationale:
A. It is more difficult to find a su- Venous return is usually better in the
perficial vein in the feet and an- upper extremities. Cannulation of the
kles. veins in the lower extremities increas-
es the risk of thrombus formation (B)
B. A decreased flow rate could re- which, if dislodged, could be life-threat-
sult in the formation of a thrombo- ening. Superficial veins are often very
sis. easy (A) to find in the feet and legs.
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