HESI Fundamentals Quizlet

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A client has a nursing diagnosis of, 'Spiritual distress related to a loss of hope, secondary to impending death.' What intervention is best for the nurse to implement when caring for this client?

  • A. Help the client accept the final stage of life.
  • B. Assist and support the client in establishing short-term goals.
  • C. Encourage the client to make future plans, even if they are unrealistic.
  • D. Instruct the client's family to focus on positive aspects of the client's life.
Correct Answer: B

Rationale: When a client is experiencing spiritual distress due to a loss of hope related to impending death, it is crucial for the nurse to assist and support the client in establishing short-term goals. This approach helps the client maintain hope and a sense of purpose, as achieving immediate goals can provide a sense of accomplishment and meaning. While acceptance of the final stage of life is important, helping the client set short-term goals is a more immediate and effective intervention in addressing spiritual distress.

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The healthcare provider is caring for a client diagnosed with type 2 diabetes mellitus. Which intervention should the healthcare provider implement to assess the client's glycemic control?

  • A. Monitor fasting blood glucose levels
  • B. Check urine for ketones
  • C. Evaluate hemoglobin A1c levels
  • D. Assess the client's dietary intake
Correct Answer: C

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

Which intervention is most important when caring for a client with a chest tube?

  • A. Keep the drainage system at chest level.
  • B. Ensure that the chest tube is clamped at all times.
  • C. Strip the chest tube every shift.
  • D. Ensure that the chest tube is connected to a water-seal drainage system.
Correct Answer: D

Rationale: The most crucial intervention when caring for a client with a chest tube is to ensure that the chest tube is connected to a water-seal drainage system (D). This system helps maintain proper lung expansion and prevents complications. Keeping the drainage system at chest level (A) is important to facilitate drainage, but not as critical as ensuring the connection to the drainage system. Clamping the chest tube (B) is unnecessary and can lead to serious issues. Stripping the chest tube (C) is an outdated practice and can cause harm rather than benefit.

A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump?

  • A. 13 ml/hour.
  • B. 63 ml/hour.
  • C. 80 ml/hour.
  • D. 125 ml/hour.
Correct Answer: B

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

During a client assessment, the healthcare provider is evaluating cranial nerve function. Which assessment finding suggests that cranial nerve II is intact?

  • A. The client can hear a whisper from 1 to 2 feet away.
  • B. The client can identify an object by touch.
  • C. The client can shrug the shoulders against resistance.
  • D. The client can read a Snellen chart from 20 feet away.
Correct Answer: D

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

The client with chronic obstructive pulmonary disease (COPD) is being taught pursed-lip breathing by the nurse. What is the purpose of this technique?

  • A. To promote oxygenation by removing secretions.
  • B. To reduce the amount of air trapped in the lungs.
  • C. To increase the amount of carbon dioxide exhaled.
  • D. To slow the respiratory rate and improve air exchange.
Correct Answer: C

Rationale: Pursed-lip breathing is used to increase the amount of carbon dioxide exhaled (C) in clients with chronic obstructive pulmonary disease (COPD). By doing so, it helps prevent air trapping and enhances gas exchange, ultimately improving respiratory efficiency. While removing secretions (A), reducing air trapping (B), and slowing the respiratory rate (D) can be associated benefits, the primary goal of pursed-lip breathing is to optimize carbon dioxide elimination and enhance breathing mechanics.