Hesi rn fundamentals

Question 1: View

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

A. Elevate the head of bed 45 degrees. B. Review the advanced directive document. C. Irrigate the nasogastric tube with water. D. Perform oropharyngeal suctioning.

Explanation

A. While elevating the head of the bed is generally recommended for clients with NG tubes to prevent aspiration, it is not the immediate priority when the client is actively vomiting and choking. This action might be taken after the airway is cleared.
B. Reviewing the advanced directive is important for end-of-life care planning, but it does not address the immediate life-threatening situation of the client choking.
C. Irrigating the NG tube is not appropriate in this situation as the client is actively vomiting and choking, indicating a potential airway obstruction.
D. The client is experiencing a life-threatening situation requiring immediate intervention to clear the airway. Oropharyngeal suctioning will remove any vomitus or secretions obstructing the airway and allow the client to breathe effectively.

Question 2: View

A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

A. Apply wrist restraints to prevent wandering. B. Leave the door to the client's room open slightly. C. Administer a PRN sedative prescription. D. Provide a back rub at bedtime.

Explanation

A. While restraints can prevent falls, they are a last resort and can cause psychological distress and physical harm. They should be avoided if possible.
B. This is a safety hazard as it increases the risk of falls and accidents.
C. Sedatives should be used cautiously in older adults as they can increase confusion and fall risk. They should be considered as a last resort after other interventions have failed.
D. This is the most appropriate initial intervention. A back rub promotes relaxation and sleep, which can help reduce confusion and wandering. It's a non-pharmacological approach that focuses on comfort and well-being.

Question 3: View

The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

A. Determine the client's activity tolerance. B. Record the client's ability to perform ADLs safely. C. Teach the client to shorten the stride to prevent falls. D. Initiate a fall risk protocol for the client.

Explanation

A. This is the most appropriate next step. While the client's gait is currently stable, it's essential to assess how long the client can maintain this level of activity without experiencing fatigue or shortness of breath. This information will help in planning appropriate exercise and activity levels.
B. This is a necessary step, but it should be done after determining the client's activity tolerance.
C. There is no indication that the client's stride is too long or that they are at risk for falls based on the information provided. Changing their gait pattern without a specific reason could be detrimental.
D. There is no evidence to suggest the client is at increased risk for falls based on the information given. Initiating a fall risk protocol without justification could lead to unnecessary interventions and anxiety for the client.

Question 4: View

The nurse is teaching the client to self administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse include?

A. Massage the injection site to increase absorption. B. Rotate injections between the abdomen and gluteal areas. C. Expel the air in the prefilled syringe prior to injection. D. Inject in abdominal area at least 2 in (5.1 cm) from the umbilicus.

Explanation

A. Massaging the injection site is generally not recommended for low molecular weight heparin injections. Massaging can cause irritation, bruising, or increase the risk of bleeding. LMWH should be injected without massaging the site to avoid these potential complications.
B. For subcutaneous injections of LMWH, the preferred site is typically the abdomen rather than the gluteal area. Rotating injection sites within the abdomen (but not including the gluteal area) helps to prevent tissue damage and improves absorption.
C. Expelling the air from a prefilled syringe is generally not recommended for LMWH injections. Expelling
the air could potentially lead to incorrect dosing or reduce the medication’s efficacy.
D. Injecting LMWH in the abdominal area is recommended, and it is crucial to avoid injecting too close to the umbilicus. The instruction to inject at least 2 inches (5.1 cm) from the umbilicus helps to ensure that the injection is in an area with sufficient subcutaneous tissue and reduces the risk of irritation or bleeding.

Question 5: View

A client with chronic fecal incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?

A. Encourage the use of incontinence briefs. B. Assist to a bedside commode 30 minutes after meals. C. Administer a glycerin suppository 15 minutes after meals. D. Insert a rectal tube at specified intervals.

Explanation

A. While incontinence briefs can provide comfort and protection, they do not address the underlying issue of fecal incontinence and may contribute to a sense of helplessness.
B. This is the most appropriate option. Establishing a regular bowel routine is crucial for bowel training. After meals, the gastrocolic reflex stimulates bowel motility, making this an ideal time to attempt bowel movements.
C. Suppositories can stimulate bowel movements but they should not be used routinely as they can lead to dependency. The goal of bowel training is to establish a regular pattern without relying on medications.
D. Similar to suppositories, rectal tubes should be avoided as they can disrupt the natural bowel function and lead to dependency.

Question 6: View

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

A. Establish a regular time for going to bed and getting up. B. Avoid drinking caffeinated beverages late in the day. C. Drink a mixture of warm water, whiskey, and honey at bedtime. D. Take an afternoon nap to make up for missed sleep. E. Ask the healthcare provider for a mild sedative for bedtime.

Explanation

A. Maintaining a consistent sleep schedule helps regulate the body’s internal clock, which can improve sleep quality and help with falling asleep and waking up at desired times. Going to bed and waking up at the same time every day supports a healthy sleep routine and is a fundamental principle of good sleep hygiene.
B. Caffeine is a stimulant that can interfere with the ability to fall asleep and stay asleep. Avoiding caffeinated beverages later in the day helps reduce the risk of sleep disturbances and can contribute to improved sleep quality.
C. While warm drinks like herbal tea or milk might be soothing before bed, alcohol (such as whiskey) can actually disrupt sleep patterns and reduce sleep quality. Alcohol may initially make a person feel drowsy, but it can lead to fragmented sleep and waking up during the night.
D. Napping during the day can be beneficial if done correctly, but long or late afternoon naps can
interfere with nighttime sleep. It’s usually better to focus on improving nighttime sleep quality rather than relying on naps. Short naps earlier in the day (20-30 minutes) can be refreshing without affecting nighttime sleep, but this depends on individual sleep patterns and needs.
E. While a mild sedative might be prescribed in some cases, relying on medication for sleep should not be the first line of treatment.

Question 7: View

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a fort?

A. Placing a client in restraints without having a healthcare provider's order. B. Administering the medication to a client behind a closed curtain. C. Informing a client that the medication being administered is a vitamin. D. Enlisting security personnel to assist with restraining the client.

Explanation

A. This is a serious violation of patient rights and could have legal consequences. Restraints should only be used as a last resort and with a healthcare provider's order. However, it is not considered a fort.
B. This is not ideal, but it might be necessary in an emergency situation to protect the nurse and other patients. It's essential to maintain privacy and dignity, but safety is paramount.
C. Informing a client that the medication being administered is a vitamin. This is a clear violation of patient rights and trust. Honesty and transparency are essential in the nurse-patient relationship.
D. Enlisting security personnel to assist with restraining the client might be necessary in an emergency situation to protect the client and staff. If the client is a danger to themselves or others, seeking additional help is appropriate.

Question 8: View

The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a counter top. Which action should the nurse implement?

A. Communicate the colleague's activities to the unit charge nurse. B. Send an email to facility administrators reporting the action. C. Warn the colleague that copying health information is unlawful. D. Dispose the copies and continue with client care assignments.

Explanation

A. The charge nurse is responsible for the unit and can address the situation directly with the colleague, providing necessary education or disciplinary action if needed.
B. This might escalate the situation unnecessarily and bypass the chain of command. It is generally better to address issues within the immediate work environment first.
C. While this might be true, it is not the most effective way to handle the situation. A more professional approach is to involve the charge nurse.
D. This might seem like a quick solution, but it does not address the underlying issue of the colleague's behavior. It is important to report the incident to protect patient privacy and ensure compliance with facility policies.

Question 9: View

The nurse enters a client's room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

A. "This is a bad time. I can see you are upset. I can come back later." B. "I am sorry to disturb you at a difficult time. This can wait until later." C. While touching the client's forearm, asks, "Would you like to talk about it?" D. Gives the client a hug and says, "It is okay to cry when you are sad."

Explanation

A. While this response acknowledges the client's distress, it may not provide the support the client
needs in the moment. Simply offering to come back later does not address the client’s emotional state
or provide an opportunity for the client to express their feelings or concerns right away.
B. This response acknowledges the client's emotional state and offers the flexibility of postponing the assessment, which respects the client's current need for space and time to process their emotions.
C. It offers the client an opportunity to talk about their feelings, which can be therapeutic and provide emotional support. The touch on the forearm, however, is a violation of personal space.
D. Giving a hug may not always be appropriate due to professional boundaries and individual comfort levels. It is important to respect personal space and cultural differences regarding physical contact.

Question 10: View

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL. vial. Which action should the nurse perform with the remainder of the medication?

A. Ask another nurse to witness the medication being discarded. B. Throw the vial into the trash in the presence of another nurse. C. Place the vial with the remainder of the medication into a locked drawer. D. Withdraw the medication into a syringe and label it with the client's

Explanation

A. Waste of controlled substances must be witnessed by another healthcare professional to maintain accurate medication records and prevent medication diversion.
B. While having a witness is good practice, simply throwing the vial into the trash is not the correct procedure for disposing of controlled substances.
C. Unused portions of controlled substances should be discarded according to facility policy, which typically involves witnessing and proper documentation.
D. This is absolutely incorrect and unsafe. This action could lead to medication errors and patient harm.