HESI Fundamentals Quizlet

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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.

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The nurse is preparing to administer 2 units of packed red blood cells (PRBCs) to a client. Which action should the nurse implement to ensure the client's safety?

  • A. Obtain informed consent from the client for the PRBC transfusion
  • B. Review the client's medical history for a history of transfusion reactions
  • C. Assess the client's baseline vital signs before starting the transfusion
  • D. Verify the blood type and crossmatch with another licensed nurse
Correct Answer: D

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs?

  • A. Autopsy of the body is prohibited.
  • B. Blood transfusions are forbidden.
  • C. Alcohol use in any form is not allowed.
  • D. A vegetarian diet must be followed.
Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

The health care provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication?

  • A. The client will experience increased tolerance to the drug's effects and may need a higher dose.
  • B. The onset of action of the drug will occur more rapidly, resulting in a more rapid effect.
  • C. The medication will be more highly protein-bound, increasing the duration of action.
  • D. The therapeutic index will be increased, placing the client at greater risk for toxicity.
Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

The healthcare provider selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the healthcare provider use to identify placement of the IV access?

  • A. Left brachial vein
  • B. Right cephalic vein
  • C. Dorsal side of the right wrist
  • D. Right upper extremity
Correct Answer: B

Rationale: The cephalic vein is a large, superficial vein located on the radial side of the forearm, making it the preferred site for IV access. It is often the best choice for insertion of an IV catheter due to its accessibility and low risk of complications, such as infiltration. Therefore, documenting the use of the right cephalic vein for IV access is crucial for accurate and safe patient care.

A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal cannula at 4 liters per minute. Which assessment finding indicates a need for immediate action?

  • A. The client's respiratory rate is 14 breaths per minute.
  • B. The client's oxygen saturation is 92%.
  • C. The client reports shortness of breath.
  • D. The client's respiratory rate is 24 breaths per minute.
Correct Answer: C

Rationale: A report of shortness of breath (C) indicates that the client is not tolerating the oxygen therapy well and may need an adjustment. Shortness of breath is a critical symptom in a client with COPD, as it signifies potential respiratory distress. A respiratory rate of 14 (A), oxygen saturation of 92% (B), and respiratory rate of 24 (D) are not as immediately concerning as they may still fall within acceptable ranges for a client with COPD.

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