HESI RN
HESI RN Fundamentals of Nursing Questions
Extract:
Question 1 of 5
A client reports pain, numbness, and tingling sensations in the lower legs. How should the nurse document this finding?
Correct Answer: B
Rationale: Symptoms indicate nerve damage.
Extract:
History and Physical
The client is a 44-year-old with cerebral palsy who is non-verbal and has a severe intellectual disability. He requires total care at home, which is provided by his two sisters, a home health nurse, and an unlicensed home health aide. The client is currently in the hospital for a lower respiratory infection.
Nurses Notes
1000
- Noted the client's clothes and sheets are wet. The client voided approximately 75 mL of urine. The client's sister says that he usually wears adult diapers at home as he is unable to communicate when he needs to void.
Question 2 of 5
Identify from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
| ptions | Reflex urinary incontinence | Urge incontinence | Functional incontinence | Overflow urinary incontinence |
|---|---|---|---|---|
| Potential Conditions | ||||
| Actions to Take | ||||
| Parameters to Monitor |
Correct Answer:
Rationale: Overflow urinary incontinenceThis is the correct choice because overflow urinary incontinence is the involuntary loss of urine due to a distended bladder that cannot empty completely. The client has cerebral palsy, which can affect the bladder muscles and nerves, causing them to lose coordination and contractility. The client is also non-verbal and has severe intellectual disability, which can impair his ability to sense or communicate the need to void. The client's clothes and sheets are wet, indicating that he has leaked urine. The client voided approximately 75 mL of urine, which is a small amount for an adult male. These signs suggest that the client has overflow urinary incontinence.Actions to Take Provide skin care
This is a correct choice because the nurse should provide skin care to the client who has overflow urinary incontinence. The nurse should cleanse the perineal area with mild soap and water, pat dry, and apply a barrier cream or ointment to protect the skin from moisture and irritation. The nurse should also change the client's clothes and sheets as needed to keep him dry and comfortable.
Place an incontinence containment product under the client
This is a correct choice because the nurse should place an incontinence containment product under the client who has overflow urinary incontinence. An incontinence containment product is a device or material that absorbs or collects urine, such as a diaper, pad, or catheter. The nurse should choose an appropriate product based on the client's preferences, needs, and abilities. The nurse should also monitor the product for leakage, odor, or infection, and change it regularly.
Parameters to Monitor
Intake and output
This is a correct choice because the nurse should monitor the intake and output of the client who has overflow urinary incontinence. The nurse should measure and record the amount and type of fluids that the client consumes and excretes. The nurse should also note the color, clarity, odor, and specific gravity of the urine. The nurse should compare the intake and output with the normal ranges for the client's age, weight, and condition. The nurse should report any abnormal findings or changes to the health care provider.
Post-void residual
This is a correct choice because the nurse should monitor the post-void residual of the client who has overflow urinary incontinence. Post-void residual is the amount of urine left in the bladder after voiding. The nurse can measure it by using a bladder scanner or inserting a catheter after the client voids. A normal post-void residual is less than 50 mL for an adult male. A high post-void residual indicates that the bladder is not emptying completely, which can lead to overflow urinary incontinence. The nurse should report any high post-void residual to the health care provider
Extract:
Question 3 of 5
While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?
Correct Answer: C
Rationale: Occult blood test uses current stool.
Question 4 of 5
The nurse identifies several nursing problems for a client with paraplegia who has been having fecal incontinence and diarrhea. The client's parent is the primary caregiver. In planning care, the nurse should determine which problem is the highest priority?
Correct Answer: A
Rationale: Fluid deficit is life-threatening.
Question 5 of 5
A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?
Correct Answer: C
Rationale: Smoking cessation significantly reduces cardiac risk.