Fundamentals of Nursing HESI

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A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy?

  • A. A client who has asthma.
  • B. A client who has diabetes.
  • C. A client who has hypertension.
  • D. A client who has a history of depression.
Correct Answer: A

Rationale: The correct answer is A: a client who has asthma. Essential oils have the potential to trigger asthma symptoms due to their strong scents and chemical components. Consulting with the healthcare provider is crucial before using aromatherapy with essential oils to ensure the safety and well-being of the client with asthma. Choices B, C, and D do not pose immediate risks with aromatherapy use, making them less of a priority for consultation compared to asthma. Clients with diabetes, hypertension, or depression do not have the same immediate risks associated with the use of aromatherapy as clients with asthma. However, it is still advisable for the nurse to be aware of any potential interactions or contraindications with these conditions and consult with the provider if needed.

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A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?

  • A. When do you usually bathe, in the morning or evening?
  • B. Do you prefer a bath or a shower?
  • C. At what temperature do you prefer your bath water?
  • D. Are you able to help with your hygiene care?
Correct Answer: D

Rationale: The priority assessment question before beginning hygiene care for a new resident is determining if the resident is able to help with their hygiene care. This is essential to ensure the resident's safety during the procedure and prevent any potential injuries. Options A, B, and C, while relevant to providing personalized care, are not as critical as assessing the resident's ability to participate in their own hygiene care. Asking about the resident's ability to assist also promotes their independence and autonomy in self-care activities.

An assistive personnel tells the nurse, 'I am unable to find a large blood pressure cuff for a client who is obese. Can I just use the regular cuff if I can get it to stay on?' The nurse replies that taking the blood pressure of a morbidly obese client with a regular blood pressure cuff will result in a reading that is:

  • A. Low
  • B. High
  • C. Inaccurate
  • D. Unaffected
Correct Answer: B

Rationale: Using a regular blood pressure cuff on a morbidly obese client will lead to a falsely high blood pressure reading. This occurs because the cuff is not appropriately sized for the client's arm circumference, resulting in increased pressure on the artery and an inaccurate high reading. Choice A is incorrect because the reading will be falsely high, not low. Choice C is incorrect as the reading will not be accurate with an incorrectly sized cuff. Choice D is incorrect because the reading will be affected by using the wrong cuff size.

The healthcare provider is assessing a client with suspected tuberculosis. Which symptom would be most concerning?

  • A. Night sweats
  • B. Weight loss
  • C. Cough with bloody sputum
  • D. Fatigue
Correct Answer: C

Rationale: Cough with bloody sputum is a hallmark symptom of tuberculosis and is highly concerning as it indicates active disease. Hemoptysis (coughing up blood) is associated with tuberculosis infection in the lungs. While night sweats and weight loss are common symptoms of tuberculosis, they are less specific than coughing with bloody sputum. Fatigue is a nonspecific symptom that can be present in various conditions and is not specific to tuberculosis.

A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be consistent with this problem?

  • A. Chest pain
  • B. Pallor
  • C. Inspiratory crackles
  • D. Heart murmur
Correct Answer: C

Rationale: Inspiratory crackles are a common finding in patients with congestive heart failure due to the accumulation of fluid in the lungs, leading to crackling sounds during inspiration. Chest pain (Choice A) is more commonly associated with conditions like angina or myocardial infarction and is not a typical symptom of congestive heart failure. Pallor (Choice B) is a general symptom of various conditions and not specific to congestive heart failure. While a heart murmur (Choice D) may be heard in some cases of congestive heart failure, it is not as consistent as inspiratory crackles in indicating the condition.

The nurse is caring for a client with a nasogastric (NG) tube. Which action should the nurse take to maintain patency of the tube?

  • A. Flush the tube with 30 ml of water before and after medication administration.
  • B. Administer the medication with food to prevent nausea.
  • C. Verify tube placement by aspirating stomach contents.
  • D. Dilute the medication with normal saline before administration.
Correct Answer: A

Rationale: To maintain the patency of a nasogastric (NG) tube, it is essential to flush the tube with 30 ml of water before and after medication administration. This action helps ensure that the tube remains open and free from blockages. Flushing the tube prevents any medication residue from causing blockages, maintaining its patency. Choice B is incorrect because administering medication with food does not relate to maintaining tube patency. Choice C is incorrect as verifying tube placement by aspirating stomach contents is related to confirming correct tube placement, not maintaining patency. Choice D is also incorrect because diluting the medication with normal saline is not primarily aimed at maintaining the tube's patency.

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