Fundamentals HESI - Nurselytic

Correct Answer: D

Rationale:
To ensure the client's safety during a blood transfusion, it is crucial to verify the blood product with another nurse before administration. This step helps confirm the correct blood type and prevents transfusion reactions. While checking the client's identification and blood type (
Choice
A) is important, the ultimate responsibility lies with confirming the blood product before administration. Monitoring vital signs (
Choice
B) is necessary during a transfusion but does not directly address verifying the blood product. Administering blood through a peripheral IV line (
Choice
C) is a common practice but does not specifically ensure that the correct blood product is being administered, which is essential for the client's safety.

Correct Answer: D

Rationale: In this scenario, the best course of action is to inform the surgeon about the client's concern. This action ensures that the surgeon is aware of the client's specific request or concern related to the procedure. By directly involving the surgeon, the client's preferences or needs can be addressed effectively, potentially avoiding any misunderstanding or dissatisfaction.
Choice A has been corrected to 'Notify the surgeon of the client's concern' as the operating room staff may not have the authority to make changes to the permit. Having the client sign a new surgical permit (
Choice
B) may not be necessary if the concern can be addressed by informing the surgeon, making
Choice B less efficient. Adding the client's concern to the permit (
Choice
C) without consulting the surgeon may not align with the standard procedure and could lead to confusion or legal issues if the surgeon is not aware of the client's specific requests.

Correct Answer: A

Rationale: The correct answer is A: Advance directives serve to indicate the forms of medical treatment a client wishes to receive or decline in the event they are unable to communicate their preferences. This legal document allows individuals to make decisions about their future healthcare.
Choice B is incorrect as advance directives do not specify the client's preferred hospital for treatment.
Choice C is incorrect as advance directives do not determine the client's daily medication schedule; this is typically addressed in a medication administration record.
Choice D is incorrect as advance directives do not outline the client's financial status and insurance coverage, but rather focus on healthcare treatment preferences.

Correct Answer: B

Rationale:
To calculate the correct dose of 15 mg, the LPN/LVN should administer 1.5 ml of Lasix (20 mg/2 ml). This calculation ensures precise dosing.
Choice A (1 ml) is too low and would provide only 10 mg, while choice C (1.75 ml) and choice D (2 ml) would exceed the prescribed dose, resulting in potential adverse effects. It is important for the LPN/LVN to administer the exact prescribed dose to ensure therapeutic efficacy and avoid unnecessary complications.

Correct Answer: A

Rationale: The correct answer is A. Asking the client what can be done to help overcome the fear of self-injections demonstrates empathy, understanding, and a willingness to support the client in addressing their barriers. This approach facilitates open communication, acknowledges the client's feelings, and involves them in the decision-making process.

Choices B and C are authoritarian and may increase resistance in the client by being directive and not considering the client's perspective.
Choice D, while positive, does not directly address the client's fear and resistance to self-injections, missing the opportunity to explore the underlying issues.