Hesi review
A client has a nasogastric tube connected to low intermittent suction. When administering medications through the nasogastric tube, which
... [Show More] action should the nurse do first?
• The nurse should first turn off the suction (D) and then confirm placement of the tube in the stomach (B) before instilling the medications (C). To prevent immediate removal of the instilled medications and allow absorption, the tube should be clamped for a period of time
(A) before reconnecting the suction.
In assisting an older adult client prepare to take a tub bath, which nursing action is most important?
• To prevent burns or excessive chilling, the nurse must check the bath water temperature (A). (B, C, and D) promote comfort and privacy and are important interventions but are of less priority than promoting safety.
The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client?
• A health promotion brochure about decreasing cholesterol (C) is most important to provide this client, because the most significant risk factor contributing to development of arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. (A) does not address the underlying causes of arteriosclerosis. (B and D) are also important factors for reversing arteriosclerosis but are not as important as lowering cholesterol (C).
The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next?
• The client has demonstrated a purposeful response to pain, which should be documented as such (A). Response to painful stimulus is assessed after response to verbal stimulus, not before (B). There is no indication for placing the client on seizure precautions (C). Reporting (D) is nonpurposeful movement.
An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement?
• Barbiturates cause central nervous system (CNS) depression and individuals taking these medications are at greater risk for falls. The nurse should assist the client to the bathroom (A). A bedpan (B) is not necessary as long as safety is ensured. Whether the client needs to void or have a bowel movement, (C) is irrelevant in terms of meeting this client's safety needs. There is no indication that this client cannot voice her or his needs, so assessment of the bladder is not needed (D).
A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond?
• Ask him to rate his pain on a scale of 1 to 10. Obtaining a subjective estimate of the pain experience by asking the client to rate his pain (A) helps the nurse determine which pain medication should be administered and also provides a baseline for evaluating the effectiveness of the medication. Medicating for pain should not be delayed
so that it can be used as a sleep medication (B). (C) is judgmental. (D) should be used as an adjunct to pain medication, not instead of medication.
The nurse is instructing a 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?
• "Compress the inhaler while slowly breathing in through your mouth." The medication should be inhaled through the mouth simultaneously with compression of the inhaler (B). This will facilitate the desired destination of the aerosol medication deep in the lungs for an optimal bronchodilation effect. (A, C, and D) do not allow for deep lung penetration.
While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement?
• Encourage the client to see the clinic's grief counselor. The client is exhibiting normal grieving behaviors, so referral to a grief counselor (A) is the most important intervention for the nurse to implement. (B) is indicated, but is not a high-priority intervention. (C) is irrelevant at this time but might be important when determining the client's risk for contracting the illness. An antidepressant may be indicated (D), depending on further assessment, but grief counseling is a better action at this time because grief is an expected reaction to the loss of a loved one.
The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?
• "This is a new pill I have never taken before." The client's recognition of a "new" pill requires further assessment (D) to verify that the medication is correct, if it is a new prescription or a different manufacturer, or if the client needs further instruction. The time difference may not be as significant in terms of its effect, but this should be explained (A). Although comments about cost (B) should be considered when developing a discharge plan, (D) is a higher priority. The client's feelings (C) should be acknowledged, but observation of the five rights of medication administration is most essential.
Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens will be coming to get me soon!" and falls asleep. Which action should the nurse implement next?
• Assess the client's neurologic status. This statement may indicate that the client is confused. Informed consent must be provided by a mentally competent individual, so the nurse should further assess the client's neurologic status (B) to be sure that the client understands and can legally provide consent for surgery. (A) does not provide sufficient follow-up. If the nurse determines that the client is confused, the surgeon must be notified (C) and permission obtained from the next of kin (D).
Which serum labor [Show Less]