HESI RN FOUNDATIONS OF NURSING 2

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?

Good Samaritan immunity

The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?

Reporting a change in a client's condition to the healthcare provider.

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 well-approximated incision site

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?

perform oropharyngeal suctioning (to clear the airway)

What medication error prevention techniques would have helped to avoid this error?

Select all that apply.

- document all medication in the electronic record as soon as it is given

- involve and educate clients in medication administration

When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

Determine apical pulse rate and rhythm

The nurse is teaching a client about use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

Washes hands before handling the needle and syringe.

The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

Inflate blood pressure cuff to 120 mm Hg.

The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

Demonstrate proper securing of the restraints.

The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the nurse the need for additional training?

Places the client in a supine position.

The palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include plan of care?

Keep mucous membranes moist.

A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?

Whether they contain pulp or fruit.

A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

Provide a back rub at bedtime.

The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a counter top. Which action should the nurse implement?

Communicate the colleague's activities to the unit charge nurse.

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

2+ edema of fingers and hands.

The nurse is assessing a client who is having pain of the right upper abdominal area. To assess the quality of the client's abdominal pain, which approach should the nurse use?

Ask the client to describe the pain.

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication mg/mL vial. Which action should the nurse perform with the remainder of the medication?

Ask another nurse to witness the medication being discarded.

The nurse is interviewing a client with lower abdominal pain and dysuria, and needs to question the client about sexual activity. Which approach is best for the nurse to use?

Begin with questions that are less sensitive in nature.

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

Basilar lung sounds that are diminished in the left lung

A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

Apply the client's positive airway pressure device.

The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

Puts on new gloves when entering a client's room.

The nurse is teaching a client about a newly prescribed medication. To confirm that the client is learning the critical information, which strategy is most important for the nurse to include during the instruction?

Ask the client for learning feedback

The nurse enters a client's room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

While touching the client's forearm, asks, "Would you like to talk about it?"

The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

Use positive reinforcement to affirm that the procedure is being performed correctly. – it is only for children 3 years and younger where you pull it down and back

An older adult client with heart failure has a signed do not resuscitate (DNR) form to put in the medical record. The unlicensed assistive personnel (UAP) reports that the client is not breathing, and the nurse confirms the UAP's findings. Which action should the nurse take next?

Report client's status to the healthcare provider.

The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear gloves?

Using the syringe to remove the specimen from the catheter.

A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

Have the client demonstrate prescribed wound care.

A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

"Dressing must be a frustrating experience for you."

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

risk for impaired skin integrity

After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

Make an electronic addendum following the 1400 documentation.

When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain?

When the client voided following catheter removal.

The nurse is caring for a client with type 2 diabetes mellitus who had surgery for a large bowel resection with a colostomy placement. The client has now developed hyperglycemia which require self-injections of insulin after discharge. When designing the postoperative plan of care, which outcome statement should the nurse use?

The client will demonstrate ability to change the ostomy bag in two days.