Fundamentals HESI

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A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching they received about pain management?

  • A. "It might help me to listen to music while I'm lying in bed."
  • B. "I will use the pain medication as prescribed to manage the pain."
  • C. "I will request a different type of pain medication if the pain persists."
  • D. "I will ask for a physical therapist to help with the pain."
Correct Answer: A

Rationale: The correct answer is A. Listening to music is a non-pharmacological method to help manage mild pain, reflecting an understanding of pain management strategies. It shows the client's grasp of non-pharmacological pain management techniques taught preoperatively. Choice B, while important, only addresses pharmacological pain management, omitting other strategies discussed in preoperative teaching. Choice C jumps to changing medications without considering non-pharmacological methods first, indicating a narrow approach to pain management. Choice D involves a physical therapist, which is not directly related to the pain management strategies typically discussed in preoperative teaching.

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During a family assessment, a nurse is interviewing a family composed of a husband, a wife, and three children. One child is biological from this marriage, and the other two are from the wife's previous marriage. How should the nurse identify this family form?

  • A. Extended
  • B. Blended
  • C. Nuclear
  • D. Alternative
Correct Answer: B

Rationale: The correct answer is 'Blended.' This family is considered a blended family because it consists of children from previous marriages, along with the biological child of the current marriage. Choice A ('Extended') refers to a family that includes relatives beyond the nuclear family, such as grandparents or aunts/uncles. Choice C ('Nuclear') typically consists of a husband, wife, and their biological children only. Choice D ('Alternative') does not accurately describe the family structure presented in the scenario.

A client has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should be administered to soften the feces?

  • A. Oil retention
  • B. Soapsuds
  • C. Saline
  • D. Hypertonic
Correct Answer: A

Rationale: An oil retention enema is the most appropriate choice to soften and lubricate the feces before digital removal. Oil retention enemas help in making the stool easier to remove digitally due to their lubricating properties. Soapsuds, saline, and hypertonic enemas are not specifically designed to soften feces and are used for different purposes. Soapsuds enemas are used for cleansing, saline enemas for bowel evacuation, and hypertonic enemas for bowel distension in preparation for diagnostic procedures.

A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first?

  • A. Assessment
  • B. History of present illness
  • C. Plan of care
  • D. Admission date and time
Correct Answer: D

Rationale: When admitting a client to a medical-surgical unit, documenting the admission date and time is crucial as it establishes the timeline for the client's care. This information ensures accurate tracking of interventions and facilitates communication among the healthcare team. While assessment, history of present illness, and plan of care are important components of the admission process, documenting the admission date and time takes priority to establish a baseline for care delivery. Without the admission date and time, the continuity of care and coordination among healthcare providers may be compromised.

The nurse is providing oral care to a patient. In which order will the nurse clean the oral cavity, starting with the first area?

  • A. Roof of mouth, gums, and inside cheeks
  • B. Chewing and inner tooth surfaces
  • C. Outer tooth surfaces
  • D. Tongue
Correct Answer: C

Rationale: The correct sequence for oral care is to clean the outer tooth surfaces first, followed by cleaning the inner tooth surfaces, then the roof of the mouth, gums, and inside cheeks with a toothette. Brushing the tongue should be the final step in the oral care procedure. Therefore, option C is the correct choice. Options A, B, and D are incorrect because they do not follow the correct order for providing oral care to a patient.

Which statement made by a client indicates to the nurse that they may have a thought disorder?

  • A. 'I'm so angry about this. Wait until my partner hears about this.'
  • B. 'I'm a little confused. What time is it?'
  • C. 'I can't find my missing shoes. Have you seen them?'
  • D. 'I'm fine. It's my daughter who has the problem.'
Correct Answer: C

Rationale: The statement 'I can't find my missing shoes. Have you seen them?' displays disorganized thinking or speech, which is characteristic of a thought disorder. The mention of 'missing shoes' in a context that does not make logical sense suggests a disturbance in thought processes. Choices A, B, and D do not demonstrate disorganized thinking typical of thought disorders. Option A reflects emotional expression, option B indicates mild confusion, and option D shows a redirection of focus to someone else's problem.

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