HESI Fundamentals Quizlet

Question 1 of 5

While the nurse is suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?

A. Suction deeper to remove secretions. B. Gently withdraw suction tubing to allow suction or coughing out of mucus. C. Remove the suction as quickly as possible. D. Insert and remove the suction multiple times to clear secretions.

Correct Answer: B

Rationale: When a client coughs during tracheostomy tube suctioning, the nurse should gently withdraw the suction tubing. This action allows the client to cough out mucus naturally, reducing the risk of further irritation and promoting effective airway clearance.

Question 2 of 5

A male client presents to the clinic stating that he has a high-stress job and is having difficulty falling asleep at night. The client reports having a constant headache and is seeking medication to help him sleep. Which intervention should the nurse implement?

A. Determine the client's sleep and activity pattern B. Obtain a prescription for the client to take when stressed C. Refer the client for a sleep study and neurological follow-up D. Teach coping strategies to use when feeling stressed

Correct Answer: D

Rationale: Teaching coping strategies is an appropriate first intervention for a client experiencing sleep difficulties and stress. It can help manage stress and improve sleep without immediately resorting to medication. By teaching coping strategies, the nurse empowers the client to address the underlying issues contributing to his sleep problems rather than just providing a temporary solution. Referring for a sleep study and neurological follow-up may be considered later if the client's sleep issues persist despite implementing coping strategies.

Question 3 of 5

A client is admitted with a diagnosis of heart failure. Which dietary instruction should the nurse provide?

A. Increase fluid intake to 3 liters per day. B. Limit sodium intake to 2 grams per day. C. Avoid foods high in potassium. D. Increase protein intake to promote healing.

Correct Answer: B

Rationale: Limiting sodium intake to 2 grams per day (
B) is a crucial dietary instruction for clients with heart failure. It helps manage fluid retention and reduces the workload on the heart. Increasing fluid intake (
A), avoiding potassium (
C), and increasing protein intake (
D) are not appropriate dietary instructions for heart failure management.

Question 4 of 5

Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed, and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse take in response to this situation?

A. Notify the charge nurse that a medication error occurred. B. Submit a medication variance report to the supervisor. C. Document the events that occurred in the nurse's notes. D. Discard the original medication administration record.

Correct Answer: C

Rationale: In this scenario, the nurse acted appropriately by withholding the medication, consulting with the healthcare provider, and administering the newly prescribed dose, albeit with a delay. The correct course of action for the nurse is to document all these events in the nurse's notes. Documenting the sequence of actions taken is crucial for maintaining an accurate record of the client's care, ensuring transparency, and providing essential information for future reference and continuity of care.

Question 5 of 5

The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best?

A. Only refer to the client by gender. B. Identify the client only by age. C. Avoid using the client's name. D. Discuss the client another time.

Correct Answer: D

Rationale: The best nursing action is to discuss the client another time. When discussing a client's confidential information, it is essential to ensure privacy and confidentiality. Given the presence of other clients in the immediate vicinity, it is inappropriate to discuss personal details about a client's condition openly. Waiting for a more private setting is crucial to uphold the client's right to privacy and confidentiality.

Nurselytic

HESI RN

HESI RN