A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

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HESI Fundamentals 2023 Test Bank Questions

Question 1 of 5

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

Correct Answer: A

Rationale: The correct action for the nurse to take when a client has a new prescription for wrist restraints is to pad the client's wrists before applying the restraints. This is important to prevent skin breakdown and injury. Tying the restraints to the side rails of the bed (Choice B) is unsafe and can lead to potential harm for the client. Similarly, securing the restraints to the bed frame (Choice C) is not appropriate as it can restrict the client's movement and cause discomfort. Using a quick-release knot to tie the restraints (Choice D) is also incorrect as it may compromise the effectiveness of the restraints in ensuring client safety.

Question 2 of 5

A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia?

Correct Answer: A

Rationale: The correct answer is A. Nasogastric suctioning can lead to hypovolemia due to the loss of gastric fluids. Chronic constipation and syndrome of inappropriate antidiuretic hormone (SIADH) are not typically associated with hypovolemia. A toxic dose of sodium bicarbonate antacids may lead to metabolic alkalosis, not hypovolemia.

Question 3 of 5

A healthcare professional reviewing a client's health record notes a new prescription for lisinopril 10 mg PO once daily. The healthcare professional should identify this as which of the following types of prescription?

Correct Answer: C

Rationale: A prescription for once-daily medication is considered routine as it is meant for regular, daily administration to maintain therapeutic levels in the body. Single prescriptions are for one-time use only. Stat prescriptions are for immediate administration in urgent situations, while now prescriptions are also for immediate use but may have varying levels of urgency depending on the patient's condition. In this case, since the prescription is for once daily use, it falls under the category of routine prescription.

Question 4 of 5

A nurse is collecting data from a client who is reporting pain despite taking analgesics. Which of the following actions should the nurse take to determine the intensity of the client's pain?

Correct Answer: C

Rationale: Offering the client a pain scale is the most appropriate action to determine the intensity of the client's pain. Pain scales help quantify the intensity of pain, providing a standardized way to assess and compare pain levels. Asking about precipitating factors (choice A) may help identify triggers but does not directly measure pain intensity. Questioning about the location of pain (choice B) helps with localization but not with quantifying intensity. Using open-ended questions (choice D) may provide insights into the quality and experience of pain but does not provide a standardized measure of intensity.

Question 5 of 5

A client is experiencing dyspnea and fatigue after completing morning care. Which of the following actions should the nurse include in the client's plan of care?

Correct Answer: A

Rationale: Scheduling rest periods during morning care is essential for managing dyspnea and fatigue in the client. This approach allows the client to pace themselves and catch their breath, promoting comfort and reducing symptoms. It is crucial to provide breaks to prevent overwhelming the client and exacerbating their symptoms. Discontinuing morning care for 2 days (choice B) is not a suitable solution as it does not address the underlying issue and may lead to neglect of essential care. Performing all care as quickly as possible (choice C) can worsen the client's symptoms and compromise their well-being by increasing stress and exertion. Asking a family member to bathe the client (choice D) does not address the need for rest periods during care and may not be feasible or appropriate in all situations.

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