HESI NCLEX-RN FUNDAMENTALS 2022/2023
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1. The nurse is assessing several clients prior to
surgery.Which factor in a client's history poses
the
... [Show More] greatest threat for complications to occur
during surgery?
2. Urinary catheterization is prescribed for a postoperative female client who has been unable to
Taking anticoagulants for
the past year
Rationale:
Anticoagulants (B) increase the risk for bleeding during surgery, which
can pose a threat for
developing surgical complications. The healthcare
provider should be informed that the client is
taking such drugs.
Leave the catheter in
place and reattempt with
void for 8 hours.The nurse inserts the catheter, another catheter.
but no urine is seen in the tubing.What action
will the nurse take next?
3. The nurse is instructing a male client in the
proper use of a metered-dose inhaler. Which
instruction should the nurse provide the client
to ensure the optimal benefits from the drug?
4. The nurse is assisting a male client to the bathroom.When 5 feet from the bathroom door, the
client states, "I feel faint." Before the nurse can
Rationale:
It is likely that the first
catheter is in the vagina,
rather than the bladder.
Leaving the first catheter
in place will help locate the meatus when
attempting the second
catheterization
Compress the inhaler
while slowly breathing in
through your mouth.
Rationale:
The medication should
be inhaled through
the mouth simultaneously
with compression of the
inhaler
Gently lower the client to
the floor.
Rationale:
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get him to a chair, he starts to fall.What is the
priority action for the nurse to take?
5. Which nursing diagnosis has the highest priority when planning care for a client with an
indwelling urinary catheter?
6. A nurse is working in an occupational health
clinic when a male employee walks in and
states that he was struck by lightning while
working on his truck bed. He is alert but reports
feeling faint. What assessment will the nurse
perform first?
7. The nurse makes the nursing diagnosis of Potential for infection related to partial-thickness
(second-degree) and full-thickness (third-degree) burns.What intervention has the highest
priority in decreasing the client's risk of infection?
(D) is the most prudent intervention and is the priority nursing action to prevent injury to the client
and the nurse. Lowering the client to the floor
should be done when the
client cannot support his
own weight. The client
should be placed in a bed
or chair only when sufficient help is available to
prevent injury.
High risk for infection
Rationale:
Indwelling urinary
catheters are a major
source of infection
Pulse characteristics
Rationale:
Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so assessment of the
pulse rate and regularity
(A) is a priority. Since the
client is talking, he has an
open airway
Use of careful handwashing technique
Rationale:
Careful handwashing
technique (B) is the single
most effective intervention for prevention of contamination to all clients.
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8. When taking a client's blood pressure, the
nurse is unable to distinguish the point at
which the first sound was heard.What is the
best action for the nurse to take?
9. The nurse observes an unlicensed assistive
personnel (UAP) taking a client's blood pressure in the lower extremity. Which observation
of this procedure requires the nurse's intervention?
10. In taking a client's history, the nurse asks
about the stool characteristics.Which description should the nurse report to the healthcare
provider as soon as possible?
11.11.
Deflate the cuff to zero
and wait 30 to 60 seconds before reattempting
the reading.
Rationale:
Deflating the cuff for 30
to 60 seconds (C) allows
blood flow to return to the
extremity so that an accurate reading can be obtained on that extremity a
second time.
The UAP auscultates the
popliteal pulse with the
cuff on the lower leg.
Rationale:
When obtaining the blood
pressure in the lower
extremities, the popliteal
pulse is the site for auscultation when the blood
pressure cuff is applied
around the thigh. The
nurse should intervene
with the UAP who has applied the cuff on the lower
leg
Daily black, sticky stool
Rationale:
Black, sticky stool (melena) is a sign of gastrointestinal bleeding and
should be reported to
the healthcare provider
promptly
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The nurse is teaching a male client how to per- Ask the client to describe
form progressive muscle relaxation techniques the routine he is curre [Show Less]