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HESI RN Foundation of Nursing
Total Questions : 60
Showing 10 questions, Sign in for moreThe client is an 81-year-old male with a history of hypertension, heart failure, and seasonal allergies. He was admitted for pneumonia 3 days ago and is currently in the intermediate care unit. He lives with his daughter and her family. She reports that he is active and compliant with his medication regime. He walks the dog every morning and has no signs of cognitive decline at home.
0800
Received report. The client is awake and alert. Upon assessment, found a 0.7 in by 1.6 in (2 cm by 4 cm) partial thickness abrasion behind the client's right ear where the strap holding the continuous positive airway pressure (CPAP) mask was positioned.
Continuous positive airway pressure (CPAP) 10 cm H2O with supplemental oxygen 55% Adjust oxygen as needed to keep oxygen saturation greater than 91%
Activity as tolerated
Vital signs every 2 hours
Diet as tolerated
Lactated Ringers IV infusion at 90 mL/hr
Patient Data
Review was done of H and P, nurses' notes, and orders.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Explanation
Pressure sores are divided into different stages:
Stage 1= Intact skin with non-blanchable redness over a localized area
Stage 2= Partial thickness loss of dermis, shallow open ulcer with a pink base
Stage 3= Full thickness ulcer but tendons, muscles and bone are not exposed
Stage 4- Full thickness wound with exposed tendons, muscle and bone
Unstageable-Full thickness tissue loss with the base covered with an eschar or yellow, gray or brown tissue
The client already has a pressure sore that requires cleaning to remove any tissue debris that may act as nidus for infection, placing a hydrocolloid dressing protects and debrides the wound to promote healing Monitoring skin integrity is key to ensure no other pressure sores develop.
Nutritional status determines the risk of developing pressure injury and the chances of wound healing.
A nurse stops at a motor vehicle collision to provide help for a victim who is trapped in an overturned running vehicle. The nurse turns off the engine key, and asks the client to wiggle the fingers because the client's head is impinged on the roof and the neck is bent to the left shoulder. After Emergency Medical Services (EMS) arrive, the nurse reports that the victim is conscious, but is not able to talk, and then the nurse leaves the scene. Which legal action can be taken in this situation?
The nurse is assessing a client who reports a 3 day history of vomiting and diarrhea and experiencing difficulty in tolerating oral fluids. Which urine specific gravity value would the nurse expect to see on initial testing?
Reference Range:
Urine Specific Gravity [1.005 to 1.03]
The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?
An unlicensed assistive personnel (UAP) is assigned to feed a client who has received a prescription to institute droplet precautions for a bacterial meningitis infection. The UAP requests a change in assignment, reporting having not yet been fitted for a particulate filter mask. Which action should the nurse take?
The nurse is caring for a client one-week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?
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 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?
The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?
The client is a 64-year-old female with a 3 day history of cough and chest pain. She recently began to have difficulty breathing. Cardiac causes of chest pain were ruled out with laboratory tests. The client will be admitted for presumed pneumonia. The client has a history of type 2 diabetes mellitus. She takes insulin glargine 12 units in the morning and 10 units in the evening
0700
Insulin glargine 12 units given SUBQ.
0900
Azithromycin 1 gm given PO.
1900
Insulin glargine 10 units given SUBQ.
2000
Insulin glargine 10 units given SUBQ.
Patient Data
The primary nurse went on break at 1845. The covering nurse gave insulin glargine and decided to manually document the dose but forgot to enter it into the electronic health record. The primary nurse came back from break and gave a second dose of insulin because of being unaware the covering nurse gave the ordered dose.
What medication error prevention techniques would have helped to avoid this error? Select all that apply.
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