Fundamentals's HESI Practice

A client who is in the advanced stages of illness asks the nurse to contact pastoral services for support. According to the Macmillan model, which is the correct nursing intervention in this situation?

Immediately involve pastoral services while caring for the client.

A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by:

a. Promoting analgesia and circulation

b. Numbing the nerves and dilating the blood vessels

c. Promoting circulation and reducing muscle spasms

d. Causing local vasoconstriction, preventing edema and muscle spasm

D. Causing local vasoconstriction, preventing edema and muscle spasms.

A client does not take his medication regularly and is depressed. Which inference can the nurse make about the client's motivational level?

Not motivated

Which cation regulates intracellular osmolarity?

Potassium

A decrease in serum potassium causes a decrease in the cell wall pressure gradient and results in water moving out of the cell.

Which is the action of an antidiuretic hormone (ADH)?

Decreases water loss in urine.

ADH is released by the posterior pituitary gland.

Which potential health problem would the nurse include in the young adult's discharge teaching?

Accidents, including their prevention

The nurse would instruct a client with type 1 diabetes to dispose of a used syringe in which container

A plastic liquid detergent bottle with a screw top lid

Which therapeutic communication technique is a coping strategy to help the nurse and client adjust to stress?

Sharing humor

Sharing humor is a therapeutic communication technique that involves using a coping strategy that adds perspective and helps the nurse and client adjust to stress

Which statement defines the term "family resiliency"?

The family has an ability to cope with stressors.

Which activity demonstrates fine motor skills in infants aged 2 to 4 months?

Bringing objects from hand to mouth.

Indicates a fine motor skill observed in infants aged 2 to 4 months.

Which nursing practice is associated with self-regulation skill?

Reflecting on one's experience

Which action would the nurse take to decrease a risk of transmission of vancomycin-resistant enterococci (VRE)

Move the client to a private room

A client on hospice care is receiving palliative treatment. Which is the goal of palliative care for this client?

Relieve the client's discomfort

During a home visit, the nurse finds a healthy older adult person is actively practicing laughing therapy to maintain goo health without pressure or insistence from family members. Which inference about the client would the nurse make for these findings?

Intrinsically motivated.

The nurse is discussing discharge plans with a client. The client states, "Im worried about going home" The nurse responses, "Tell me more about this" Which interviewing technique did the nurse use

Exploring

A client is dying. Hesitatingly, his wife says to the nurse, "I'd like to tell him how much I love him, but I don't want to upset him." Which is the correct response by the nurse

"You should share your feelings with him while you can"

Which is the role of a case manager in a health care organization?

To follow up with the client after discharge

A case manager is an advanced practice nurse who coordinates a client's acute care in the hospital and follows up and the client after discharge.

Which caring intervention helps provide comfort, dignity, respect, and peace to a client?

Relieving pain and suffering

Which action indicates that the nurse is actively listening to the client?

Interpreting what the client is saying and restating it for clarification

Which critical thinking skill is being used when the nurse applies knowledge and experience to client care?

Explanation

When the nurse is using experience to care for clients, the critical thinking skill of explanation is being applied.

When a client expresses anxiety abut given anesthesia, which team member should sit with the person and provide comfort during the induction?

Circulating nurse

The circulating, or non sterile, nurse would sit with the client to provide comfort during induction.

Refusing to follow the prescribed treatment regiment, a client plans to leave the hospital against medical advice. Which is it important for the nurse to inform the client of?

The client must accept full responsibility for possible undesirable outcomes.

Which skill in critical thinking requires the nurse to be orderly in data collection?

Interpretation

Interpretation is involved in the orderly collection of data. When information about a client is collected with an open mind, then the skill called analysis is being used.

Which professional standard is important for critical thinking?

Evaluation criteria

An evaluation criterion is an important professional standard required for critical thinking.

The nurse on the medical-surgical unit tells other staff members, "That client can just wait for the lorazepam; I get so annoyed when people drink too much" Which does this nurse's comment reflect?

Demonstration of personal bias.

Which critical thinking skill in nursing practice requires the nurse to possess knowledge and experience for choose care strategies for clients?

Explanation

Explanation requires knowledge and experience for choosing strategies for care for clients.

A client has been placing used insulin needles in a container sealed with heavy-duty tape. Where would the nurse tell the client to dispose of the container?

The local hazardous waste collection site

Which therapeutic communication technique is used when the nurse and a client have a conversation and the client begins to repeat the conversation to her/himself.

Focusing

Focusing is a therapeutic communication technique that is useful when clients being to repeat themselves.

Which critical thinking skill will help a student nurse avoid making assumptions about clients.

Analysis

Use of analysis allows the student nurse to be open minded while looking at the clients info and to avoid making assumptions.

A client is likely t undergo reconstructive surgery for which purpose?

To restore function and/or appearance

The nurse records the client's weight and BMI at a healthy range, but the client states, "I wish I were as thin as my coworkers" Which culturally bound condition i s the client at risk for?

Anorexia nervosa

A client which chronic renal failure stops responding to the treatment. On examination, the primary health care provider determines that the client is terminally ill. Which is the correct nursing intervention in this situation.

Encourage the family to provide palliative care to the patient.

Clients who are terminally ill and no longer respond to treatment are in need of palliative care.

A Spanish speaking client is being cared for by English speaking nursing staff. Which communication technique would be correct for the nurse to use when discussing health care decisions with the client.

Contact an interpreter provided by the hospital

Which is the most important nursing action involved in caring for a client receiving medications?

Administering the medication.

Two nurses are planning to help a client with one-sided weakness move up in bed. Which principle of body mechanics would the nurse observe?

Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head fo the bed, and the move the client.

A client with cystic fibrosis asks why the percussion procedure is being performed. Which rationale would the nurse give to the client?

It loosens pulmonary secretions

Postural drainage and percussion, also known as chest physical therapy (CPT), is a way to help clients with CF breathe with less difficulty and stay healthy. Intervention uses gravity and slapping the chest to loosen the mucus in the lungs s it can be removed by coughing.

Which concept refers to respecting the rights of others?

Open-mindedness

Refers to respecting the rights of others and being tolerant of different viewpoints

When caring for a client who is receiving eternal feedings, the nurse would take which measure to prevent aspiration

Elevate the head of the bed between 30 and 45 degrees

A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. Which type of room would the nurse assign this client

Negative-airflow room

Which assessment finding is associated with depression?

The client has islands of intact memory

The nurse is caring for a surgical client who develops a wound infection during hospitalization. Which classification would this infection belong to

Nosocomial

Nosocomial infection is acquired in a health care setting.