Review Nightdale College HESI Exam Fundamental of Nursing Exam 1

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Nightdale College HESI Exam Fundamental of Nursing Exam 1

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Total Questions : 44

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Question 1:

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

A. Remove nasal cannula. B. Increase the oxygen to 3 L/minute. C. Verify placement of pulse oximeter. D. Switch to a non-rebreather mask.

Answer and Explanation

Choice A:

Removing the nasal cannula is not appropriate as it would deprive the client of supplemental oxygen. The client's oxygen saturation is below the normal range of 95% to 100%, indicating hypoxemia.

Choice B:

Increasing the oxygen to 3 L/minute is the best action as it would provide more oxygen to the client and improve the oxygen saturation. The nurse should monitor the client's response and adjust the oxygen flow as needed.

Choice C:

Verifying the placement of the pulse oximeter is a good practice, but it is not the priority action. The nurse should first intervene to correct the hypoxemia and then check the accuracy of the pulse oximeter.

Choice D:

Switching to a non-rebreather mask is not necessary as it would deliver a high concentration of oxygen (up to 100%) that may be excessive for the client. A nasal cannula can deliver oxygen from 1 to 6 L/minute, depending on the client's needs.

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Question 2:

Which equipment should the nurse use to most accurately measure a 2 mL dose of viscous liquid solution to be administered orally?

A. 3 mL syringe. B. One ounce medicine cup. C. Tuberculin syringe. D. 3 mL syringe and a sterile needle.

Answer and Explanation

Choice A:

A 3 mL syringe is not the most accurate equipment for measuring a 2 mL dose of viscous liquid solution. The syringe has a large bore and a wide graduation that may cause errors in reading the volume.

Choice B:

A one ounce medicine cup is not the most accurate equipment for measuring a 2 mL dose of viscous liquid solution. The cup has a large capacity and a low precision that may result in over or under dosing.

Choice C:

A tuberculin syringe is the most accurate equipment for measuring a 2 mL dose of viscous liquid solution. The syringe has a small bore and a fine graduation that allow for precise measurement of the volume.

Choice D:

A 3 mL syringe and a sterile needle is not the most accurate equipment for measuring a 2 mL dose of viscous liquid solution. The needle may cause the solution to stick to the inner wall and reduce the actual dose delivered.

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Question 3:

A client reports pain, numbness, and tingling sensations in the lower legs. How should the nurse document this finding?

A. Neuropathic pain B. Visceral pain C. Acute pain D. Nociceptive pain

Answer and Explanation

Choice A:

Neuropathic pain is caused by damage or dysfunction of the nervous system. It is often described as burning, shooting, or tingling sensations. The client's symptoms are consistent with neuropathic pain.

Choice B:

Visceral pain is caused by stimulation of pain receptors in the internal organs. It is often described as deep, dull, or cramping sensations. The client's symptoms are not consistent with visceral pain.

Choice C:

Acute pain is caused by a sudden or short-term injury or illness. It is often described as sharp, throbbing, or stabbing sensations. The client's symptoms are not consistent with acute pain.

Choice D:

Nociceptive pain is caused by stimulation of pain receptors in the skin, muscles, bones, or joints. It is often described as aching, sore, or pressure sensations. The client's symptoms are not consistent with nociceptive pain.

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Question 4:

The nurse is teaching a client how to self-administer low-molecular-weight heparin subcutaneously. Which instruction should the nurse include?

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

Answer and Explanation

Choice A:

This is the correct instruction as it ensures that the injection is given in a well-perfused area with minimal risk of injury to major blood vessels or organs. The umbilicus should be avoided as it may harbor bacteria or cause discomfort.

Choice B:

This is an incorrect instruction as it may result in a loss of medication or inaccurate dosing. The air bubble in the prefilled syringe should be left intact as it helps to seal the medication in the subcutaneous tissue and prevent leakage.

Choice C:

This is an incorrect instruction as it may cause irritation or inflammation of the injection sites. The gluteal area should be avoided as it has a higher risk of hitting a nerve or blood vessel. The abdomen is the preferred site for low-molecular-weight heparin injections.

Choice D:

This is an incorrect instruction as it may increase the risk of bleeding or bruising. The injection site should not be massaged or rubbed as it may dislodge the clot or damage the tissue.

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Question 5:

When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. Which should the nurse do next?

A. Assess the position of the mask on the client's face. B. Release and reinsert the flowmeter in the wall outlet. C. Attach the flowmeter to a humidification canister. D. Adjust the flow rate to the prescribed liters per minute.

Answer and Explanation

Choice A:

Assessing the position of the mask on the client's face is not the priority action. The mask may be well-fitted, but the oxygen delivery may be compromised by the faulty connection of the flowmeter.

Choice B:

Releasing and reinserting the flowmeter in the wall outlet is the best action as it may correct the problem of the loose or misaligned connection. The nurse should ensure that the flowmeter is securely attached and that the oxygen is flowing properly.

Choice C:

Attaching the flowmeter to a humidification canister is not necessary for oxygen delivery per mask. Humidification is usually added for high-flow oxygen devices such as nasal cannula or face tent.

Choice D:

Adjusting the flow rate to the prescribed liters per minute is not the appropriate action. The flow rate may be correct, but the oxygen delivery may be impaired by the hissing sound indicating a leak or obstruction.

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Question 6:

The nurse is evaluating the fluid balance of a client who was admitted yesterday with dehydration and who has been receiving IV fluids since admission. An increase in which parameter indicates to the nurse that the client is rehydrating?

A. Urine specific gravity B. Serum hematocrit C. Pulse rate D. Urinary output

Answer and Explanation

Choice A:

Urine specific gravity is a measure of the concentration of solutes in the urine. It is inversely related to the hydration status of the client. A high urine specific gravity indicates dehydration, while a low urine specific gravity indicates overhydration.

Choice B:

Serum hematocrit is a measure of the percentage of red blood cells in the blood. It is also inversely related to the hydration status of the client. A high serum hematocrit indicates dehydration, while a low serum hematocrit indicates overhydration.

Choice C:

Pulse rate is a measure of the frequency of the heartbeats. It is directly related to the hydration status of the client. A low pulse rate indicates dehydration, while a high pulse rate indicates overhydration.

Choice D:

Urinary output is a measure of the amount of urine produced by the kidneys. It is directly related to the hydration status of the client. A low urinary output indicates dehydration, while a high urinary output indicates overhydration.

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Question 7:

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

Answer and Explanation

Choice A:

Reviewing the advanced directive document is not the priority action. The nurse should first intervene to clear the airway and prevent aspiration of vomitus.

Choice B:

Elevating the head of the bed 45 degrees is a good practice, but it is not sufficient to relieve the choking. The nurse should also perform suctioning to remove the vomitus from the mouth and throat.

Choice C:

Performing oropharyngeal suctioning is the best action as it helps to clear the airway and prevent aspiration of vomitus. The nurse should use a Yankauer suction catheter and apply intermittent suction while moving the catheter around the mouth and throat.

Choice D:

Irrigating the nasogastric tube with water is not appropriate as it may worsen the vomiting and choking. The nurse should stop the enteral feeding and clamp the tube until the client's condition is stabilized.

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Question 8:

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?

A. Positive external places B. Emotional reflection C. Motivational phrases D. Tranquil sounds

Answer and Explanation

Choice A:

Positive external places are images of pleasant and relaxing environments that can distract the client from the pain and induce a sense of calmness and well-being. Examples of positive external places are a beach, a garden, or a mountain.

Choice B:

Emotional reflection is a process of exploring and expressing one's feelings and emotions. It may be helpful for some clients to cope with stress and anxiety, but it is not the best focus for guided imagery for chronic pain. Emotional reflection may trigger negative emotions or memories that can worsen the pain perception.

Choice C:

Motivational phrases are statements that encourage and inspire the client to achieve a goal or overcome a challenge. They may be useful for some clients to boost their self-confidence and self-efficacy, but they are not the best focus for guided imagery for chronic pain. Motivational phrases may not be effective in reducing the pain intensity or duration.

Choice D:

Tranquil sounds are noises that create a soothing and peaceful atmosphere. They may be helpful for some clients to relax and fall asleep, but they are not the best focus for guided imagery for chronic pain. Tranquil sounds may not be enough to divert the client's attention from the pain or create a positive emotional state.

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Question 9:

The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client's foot in a basin of warm water placed on the bed. Which action should the nurse take?

A. Remove the basin of water from the client's bed immediately. B. Add skin cream to the basin of water while the foot is soaking. C. Remind the UAP to dry between the client's toes completely. D. Advise the UAP that this procedure is damaging to the skin.

Answer and Explanation

Choice A:

This is the correct action as it prevents the risk of spillage, scalding, or infection. The basin of water should not be placed on the bed, but on a bedside table or stand. The nurse should also check the temperature of the water and the condition of the client's foot.

Choice B:

This is an incorrect action as it may cause irritation or allergic reaction. The skin cream should not be added to the basin of water, but applied after the foot is dried and inspected. The nurse should also verify the type and amount of skin cream to be used.

Choice C:

This is an important action, but not the priority. The UAP should dry between the client's toes completely to prevent fungal growth or maceration. The nurse should also monitor the UAP's technique and provide feedback.

Choice D:

This is an inaccurate statement. The procedure of soaking the client's foot in a basin of warm water is not damaging to the skin, if done properly and safely. The nurse should explain the rationale and benefits of the procedure to the UAP.

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Question 10:

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

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

Answer and Explanation

Choice A:

Placing a client in restraints without having a healthcare provider's order is not a tort, but a violation of the client's rights. The nurse should obtain an order for restraints as soon as possible and follow the facility's policy and procedure.

Choice B:

Informing a client that the medication being administered is a vitamin is a tort, specifically a fraud. The nurse is deceiving the client and violating the principle of informed consent. The nurse should explain the purpose, benefits, and risks of the medication to the client and obtain the client's consent.

Choice C:

Enlisting security personnel to assist with restraining the client is not a tort, but a prudent action. The nurse is ensuring the safety of the client and others by seeking help from trained staff. The nurse should document the incident and the rationale for the intervention.

Choice D:

Administering the medication to a client behind a closed curtain is not a tort, but a respectful action. The nurse is maintaining the client's privacy and dignity by providing a quiet and secluded environment. The nurse should monitor the client's response and report any adverse effects.

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Question 11:

Which explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning?

A. The technique is intended to maintain straight spinal alignment. B. Using two or three people increases client safety. C. Working together can decrease the risk of back injury to the nurses. D. Turning instead of pulling reduces the likelihood of skin damage.

Answer and Explanation

Choice A:

This is the best explanation as it describes the main goal of the log-rolling technique, which is to prevent twisting or bending of the spine. This is especially important for clients who have spinal injuries, surgeries, or disorders.

Choice B:

Using two or three people is a part of the log-rolling technique, but it is not the purpose of it. It is a means to achieve the purpose of maintaining spinal alignment. It also ensures that the client is moved smoothly and gently.

Choice C:

Working together can decrease the risk of back injury to the nurses, but it is not the purpose of the log-rolling technique. It is a benefit for the nurses, but not for the client. The nurse should focus on the client's needs and outcomes.

Choice D:

Turning instead of pulling reduces the likelihood of skin damage, but it is not the purpose of the log-rolling technique. It is an advantage for the client, but not the main reason for using the technique. The nurse should explain how the technique affects the spine, not the skin.

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Question 12:

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

A. Muscle strength and tone B. Limitations to range of motion C. Presence of rebound phenomenon D. Degree of neurosensory impairment

Answer and Explanation

Choice A:

Muscle strength and tone is not the most important assessment for the nurse to perform prior to the application of a heating pad. It may be relevant for some clients who have musculoskeletal problems, but it does not indicate the risk of thermal injury.

Choice B:

Limitations to range of motion is not the most important assessment for the nurse to perform prior to the application of a heating pad. It may be relevant for some clients who have joint stiffness or pain, but it does not indicate the risk of thermal injury.

Choice C:

Presence of rebound phenomenon is not the most important assessment for the nurse to perform prior to the application of a heating pad. It is a sign of peritoneal inflammation that occurs when pressure is released from the abdomen. It has nothing to do with the application of a heating pad.

Choice D:

Degree of neurosensory impairment is the most important assessment for the nurse to perform prior to the application of a heating pad. It indicates the client's ability to perceive heat and pain sensations. If the client has impaired neurosensory function, the nurse should avoid using a heating pad or use it with caution and frequent monitoring.

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Question 13:

A female client assigned to a mental health unit visits with her significant other during the evening. After the significant other leaves, the nurse notices that the client is more isolative and refuses to attend the evening group. Which response by the nurse is most therapeutic?

A. "Tell me about the visit with your significant other." B. "Would you like to talk for a little while?" C. "What did you enjoy about your visit tonight?" D. "I can see that you are feeling lonely."

Answer and Explanation

Choice A:

This is the most therapeutic response as it invites the client to share her feelings and thoughts about the visit. It also shows the nurse's interest and empathy for the client.

Choice B:

This is a less therapeutic response as it is vague and non-specific. It does not address the client's behavior or mood. It also puts the burden on the client to initiate the conversation.

Choice C:

This is a less therapeutic response as it assumes that the client enjoyed the visit. It may not reflect the client's true feelings or experiences. It also limits the client's expression to positive aspects only.

Choice D:

This is a non-therapeutic response as it labels the client's emotion without validation. It may not accurately describe the client's feeling or situation. It also closes the communication by making a statement instead of asking a question.

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Question 14:

A. "Tell me about the visit with your significant other." B. "Would you like to talk for a little while?" C. "What did you enjoy about your visit tonight?" D. "I can see that you are feeling lonely."

Answer and Explanation

Choice A:

This is the most therapeutic response as it invites the client to share her feelings and thoughts about the visit. It also shows the nurse's interest and empathy for the client.

Choice B:

This is a less therapeutic response as it is vague and non-specific. It does not address the client's behavior or mood. It also puts the burden on the client to initiate the conversation.

Choice C:

Choice D:

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Question 15:

A client who is on complete bedrest frequently calls the nurse for the bedpan to urinate. Which action should the nurse take to evaluate the client for urinary retention?

A. Review the chart for number of voids over the last 24 hours. B. Palpate the suprapubic region for distention. C. Evaluate the client for urinary incontinence. D. Scan the client's bladder after voiding.

Answer and Explanation

Choice A:

Reviewing the chart for number of voids over the last 24 hours is not the best action to evaluate the client for urinary retention. It may provide some information about the client's urinary pattern, but it does not indicate the amount of urine left in the bladder after voiding.

Choice B:

Palpating the suprapubic region for distention is a useful action to assess the client for urinary retention, but it is not the most accurate or reliable method. It may be difficult to palpate the bladder if the client is obese, has abdominal pain, or has bowel distention.

Choice C:

Evaluating the client for urinary incontinence is not relevant to the assessment of urinary retention. Urinary incontinence is the involuntary loss of urine, while urinary retention is the inability to empty the bladder completely.

Choice D:

Scanning the client's bladder after voiding is the best action to evaluate the client for urinary retention. It is a noninvasive and precise technique that measures the post-void residual urine volume. A normal post-void residual is less than 50 mL, while a high post-void residual indicates urinary retention.

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Question 16:

While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

A. The client's comfort level is increased when the nurse breaks eye contact to type notes into the record. B. Completing the electronic record during an interview is a legal obligation of the examining nurse. C. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically. D. The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace.

Answer and Explanation

Choice A:

This is an incorrect statement as it implies that breaking eye contact is beneficial for the client. In fact, breaking eye contact may reduce the client's trust and rapport with the nurse. The nurse should maintain eye contact as much as possible and use verbal and nonverbal cues to show active listening.

Choice B:

This is an incorrect statement as it implies that electronic documentation is mandatory for all interviews. In fact, electronic documentation is not a legal obligation, but a preferred method of recording the assessment data. The nurse should follow the facility's policy and procedure for electronic documentation and ensure the accuracy, completeness, and confidentiality of the record.

Choice C:

This is the correct statement as it acknowledges the challenge of electronic documentation during an interview. The nurse may miss some important nonverbal cues from the client, such as facial expressions, gestures, or posture, while typing on the computer. The nurse should balance the time spent on the computer and the time spent on the client and use open-ended questions and reflective statements to elicit more information.

Choice D:

This is an incorrect statement as it implies that electronic documentation is beneficial for the interview process. In fact, electronic documentation may interfere with the flow and quality of the interview. The client may feel rushed or ignored by the nurse's attention to the computer. The nurse should pace the interview according to the client's needs and preferences and use electronic documentation as a tool, not a barrier.

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Question 17:

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?

A. "The healthcare provider will share this information with you." B. "I can give you those results as soon as I get them back from the lab." C. "I'm sorry, but your child's medical information is none of your business." D. "I can only give medical information to your child because they are legally an adult."

Answer and Explanation

Choice A:

This is an incorrect response as it implies that the healthcare provider will disclose the client's laboratory results to the parents. However, the client is emancipated and has the right to privacy and confidentiality of their medical information. The nurse should respect the client's autonomy and consent.

Choice B:

This is an incorrect response as it implies that the nurse will share the client's laboratory results with the parents. However, the client is emancipated and has the right to privacy and confidentiality of their medical information. The nurse should respect the client's autonomy and consent.

Choice C:

This is an incorrect and rude response as it insults the parents and disregards their concern. The nurse should be polite and professional when communicating with the parents. The nurse should explain the legal and ethical reasons for not disclosing the client's medical information.

Choice D:

This is the correct and respectful response as it informs the parents that the client is emancipated and has the right to privacy and confidentiality of their medical information. The nurse should respect the client's autonomy and consent and only give medical information to the client or their designated representative.

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Question 18:

The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3 L/minute, and the client's oxygen saturation level is 92%. Which intervention would the nurse implement?

A. Apply lubricant to the cannula tubing. B. Place padding around the cannula tubing. C. Decrease the flow rate to 1 L/minute. D. Discontinue the use of the nasal cannula.

Answer and Explanation

Choice A:

Applying lubricant to the cannula tubing is not the best intervention as it may cause irritation or infection of the nasal mucosa. The nurse should use water-soluble gel or saline spray to moisten the nasal passages if needed.

Choice B:

Placing padding around the cannula tubing is the best intervention as it prevents friction and pressure on the skin. The nurse should use soft materials such as gauze or foam to cushion the tubing and check the skin integrity frequently.

Choice C:

Decreasing the flow rate to 1 L/minute is not an appropriate intervention as it may compromise the client's oxygenation. The nurse should maintain the prescribed flow rate and monitor the client's vital signs and oxygen saturation.

Choice D:

Discontinuing the use of the nasal cannula is not an option as it may endanger the client's life. The nurse should continue the oxygen therapy as ordered and provide comfort measures and education to the client.

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Question 19:

The nurse is teaching a client about how to use crutches. Which action performed by the client demonstrates to the nurse a correct understanding of how to use the crutches?

A. Walks with the arms fully extended. B. Fits the crutch 2 finger widths from axilla. C. Avoids adjusting the height of the hand grips. D. Holds the crutch 6 inches (15 cm) to the side.

Answer and Explanation

Choice A:

This is an incorrect action as it indicates poor posture and balance. The client should walk with the elbows slightly flexed and the shoulders relaxed.

Choice B:

This is the correct action as it ensures proper fit and comfort of the crutch. The client should fit the crutch 2 finger widths from the axilla to prevent nerve damage and pressure ulcers.

Choice C:

This is an incorrect action as it may cause pain and injury to the wrists and hands. The client should adjust the height of the hand grips to allow a 30-degree bend at the elbow.

Choice D:

This is an incorrect action as it may cause instability and falls. The client should hold the crutch 4 to 6 inches (10 to 15 cm) in front and to the side of the foot.

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Question 20:

After administering oxycodone to a client one hour ago, the client is reporting severe pain. Which intervention should the nurse implement next?

A. Encourage the client to focus on taking deep breaths. B. Tell the client the medication needs more time to work. C. Ask the UAP to offer a backrub to the client. D. Reassess the client and the level of pain.

Answer and Explanation

Choice A:

This is not the best intervention as it does not address the cause of the pain or provide adequate relief. Deep breathing may help the client to relax and cope with the pain, but it is not enough to manage severe pain.

Choice B:

This is not a true or helpful statement as it may imply that the nurse is dismissing the client's pain or delaying further action. Oxycodone is a fast-acting opioid analgesic that reaches its peak effect within 30 to 60 minutes. If the client is still in severe pain after one hour, the nurse should reassess the pain and notify the healthcare provider.

Choice C:

This is not the priority intervention as it does not address the cause of the pain or provide adequate relief. A backrub may help the client to relax and distract from the pain, but it is not enough to manage severe pain.

Choice D:

This is the best intervention as it helps the nurse to evaluate the effectiveness of the medication and the need for further intervention. The nurse should use a valid and reliable pain assessment tool and ask the client about the location, intensity, quality, and duration of the pain. The nurse should also check the client's vital signs and observe for any signs of adverse effects from the medication.

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Question 21:

While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

A. Serum potassium and sodium levels B. Neutrophil count C. Blood pH level D. Hematocrit

Answer and Explanation

Choice A:

Serum potassium and sodium levels are not relevant to the assessment of the wound infection. They are electrolytes that regulate fluid balance, nerve conduction, and muscle contraction. They may be affected by dehydration, renal failure, or diuretics.

Choice B:

Neutrophil count is the most relevant laboratory value to note before reporting the wound infection. Neutrophils are white blood cells that fight bacterial infections and inflammation. A high neutrophil count indicates an acute infection or inflammation, while a low neutrophil count indicates a compromised immune system or a chronic infection.

Choice C:

Blood pH level is not relevant to the assessment of the wound infection. It is a measure of the acidity or alkalinity of the blood. It may be affected by respiratory or metabolic disorders, such as acidosis or alkalosis.

Choice D:

Hematocrit is not relevant to the assessment of the wound infection. It is the percentage of red blood cells in the blood. It may be affected by anemia, dehydration, or polycythemia.

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Question 22:

A client's wife has just learned that her husband is terminally ill. She is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

A. Offer reassurance that she is not alone. B. Explain that alternative treatment options may be helpful. C. Encourage the wife to share her feelings. D. Remind her that her husband may still live a long time.

Answer and Explanation

Choice A:

Offering reassurance that she is not alone is not the best action to take first. It may sound dismissive of her feelings and make her feel more isolated.

Choice B:

Explaining that alternative treatment options may be helpful is not the best action to take first. It may give false hope or imply that the wife is not accepting the reality of her husband's condition.

Choice C:

Encouraging the wife to share her feelings is the best action to take first. It shows empathy and respect for her emotional state. It also allows the nurse to assess her coping skills and provide appropriate support.

Choice D:

Reminding her that her husband may still live a long time is not the best action to take first. It may contradict the medical prognosis and make the wife feel more confused and anxious.

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Question 23:

A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?

A. Smoking cessation. B. Regular exercise. C. Low-fat diet. D. Stress reduction.

Answer and Explanation

Choice A:

Smoking cessation is the most important lifestyle modification for the nurse to encourage. Smoking is a major risk factor for cardiac disease, as it increases blood pressure, heart rate, and oxygen demand, and damages the blood vessels and the heart muscle. Quitting smoking can reduce the risk of cardiac disease by 50% within one year.

Choice B:

Regular exercise is a beneficial lifestyle modification for the nurse to encourage, but not the most important one. Exercise can improve cardiovascular fitness, lower blood pressure, and reduce body weight, but it does not eliminate the harmful effects of smoking on the heart and blood vessels.

Choice C:

A low-fat diet is a helpful lifestyle modification for the nurse to encourage, but not the most important one. A low-fat diet can lower cholesterol levels and prevent atherosclerosis, but it does not reverse the damage caused by smoking to the heart and blood vessels.

Choice D:

Stress reduction is a useful lifestyle modification for the nurse to encourage, but not the most important one. Stress can trigger the release of hormones that increase blood pressure, heart rate, and oxygen demand, and can also lead to unhealthy behaviors such as smoking, overeating, and alcohol abuse. However, stress reduction alone does not address the direct effects of smoking on the heart and blood vessels.

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Question 24:

A male client with a nasogastric tube connected to low intermittent suction tells the nurse that his mouth is very dry. Which action should the nurse implement?

A. Provide oral sponge toothettes so the client can cleanse and moisten his mouth. B. Teach the client that the oral mucosa must remain dry to prevent aspiration. C. Turn the suction off while allowing the client to rinse his mouth with cool water. D. Instill 50 ml of normal saline solution into the tube and clamp the tube for one hour.

Answer and Explanation

Choice A:

Providing oral sponge toothettes is the best action to take. It helps the client to maintain oral hygiene and comfort, and prevents dryness and cracking of the oral mucosa.

Choice B:

Teaching the client that the oral mucosa must remain dry to prevent aspiration is not a correct action. The oral mucosa needs to be moist to protect it from infection and irritation. Aspiration is prevented by checking the placement of the nasogastric tube and keeping the head of the bed elevated.

Choice C:

Turning the suction off while allowing the client to rinse his mouth with cool water is not a safe action. It may increase the risk of aspiration and interfere with the function of the nasogastric tube. The suction should only be turned off when necessary, such as during medication administration or tube feeding.

Choice D:

Instilling 50 ml of normal saline solution into the tube and clamping the tube for one hour is not an appropriate action. It may cause fluid overload, electrolyte imbalance, and abdominal distension. The nasogastric tube should be flushed with 30 ml of water every 4 to 6 hours to maintain patency and prevent clogging.

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Question 25:

The nurse is assessing a client in the clinic who is frightened and does not understand English. Which intervention should the nurse implement first?

A. Request a family member to remain with the client. B. Obtain a staff member who is a bilingual interpreter. C. Use drawings that are universal for all cultures. D. Ask for the support of one of the client's friends.

Answer and Explanation

Choice A:

Requesting a family member to remain with the client is not the best intervention to implement first. It may provide some emotional support, but it does not address the communication barrier. The family member may not be able to translate accurately or objectively, and may have their own biases or emotions.

Choice B:

Obtaining a staff member who is a bilingual interpreter is the best intervention to implement first. It ensures effective communication and understanding between the nurse and the client. It also respects the client's cultural and linguistic preferences and needs.

Choice C:

Using drawings that are universal for all cultures is not the most effective intervention to implement first. It may be helpful for some simple concepts, but it may not convey the full meaning or context of the assessment. It may also be misinterpreted or misunderstood by the client.

Choice D:

Asking for the support of one of the client's friends is not the most appropriate intervention to implement first. It may violate the client's privacy and confidentiality, and may not ensure accurate or unbiased translation. The friend may not be familiar with the medical terminology or the client's condition.

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Nightdale College HESI Exam Fundamental of Nursing Exam 1

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