HESI RN Fundamentals Exam I

Extract:

Question 1 of 5

An older adult client is admitted to the medical unit following a fall at home. While undressing the client, the nurse observes that the client is wearing an adult diaper and skin breakdown is obvious over the sacral area. Which action should the nurse implement first?

A. Apply a barrier ointment to intact areas that may be exposed to moisture. B. Determine the size and depth of skin breakdown over the sacral area. C. Complete a functional assessment of the client's self-care abilities. D. Establish a toileting schedule to decrease episodes of incontinence.

Correct Answer: B

Rationale: Assessing breakdown severity guides treatment planning.

Question 2 of 5

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Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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Similar Questions

A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?

The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

An older adult client is admitted to the medical unit following a fall at home. While undressing the client, the nurse observes that the client is wearing an adult diaper and skin breakdown is obvious over the sacral area. Which action should the nurse implement first?

The nurse retrieves hydromorphone 4 mg/mL from an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM every 6 hours PRN for severe pain. How many mL should the nurse administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)

Review H and P and nurse's note.Complete the diagram by dragging 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.

HESI RN Fundamentals Exam I | Nurselytic

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