HESI Fundamentals Quizlet

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Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed, and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse take in response to this situation?

  • A. Notify the charge nurse that a medication error occurred.
  • B. Submit a medication variance report to the supervisor.
  • C. Document the events that occurred in the nurse's notes.
  • D. Discard the original medication administration record.
Correct Answer: C

Rationale: In this scenario, the nurse acted appropriately by withholding the medication, consulting with the healthcare provider, and administering the newly prescribed dose, albeit with a delay. The correct course of action for the nurse is to document all these events in the nurse's notes. Documenting the sequence of actions taken is crucial for maintaining an accurate record of the client's care, ensuring transparency, and providing essential information for future reference and continuity of care.

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A client with rheumatoid arthritis is experiencing chronic pain in both hands and wrists. Which information about the client is most important for the nurse to obtain when planning care?

  • A. Amount of support provided by family members
  • B. Measurement of pain using a scale of 0 to 10
  • C. The ability to perform ADLs
  • D. Nonverbal behaviors exhibited when pain occurs
Correct Answer: C

Rationale: Assessing the client's ability to perform activities of daily living (ADLs) is crucial in planning care for someone with chronic pain. Understanding the client's functional status helps the nurse tailor interventions to promote independence and enhance quality of life. It provides valuable insight into the impact of pain on daily activities and guides the development of a comprehensive care plan to address the client's specific needs.

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.

The healthcare professional is assessing a client with a diagnosis of peripheral arterial disease (PAD). Which assessment finding is most indicative of this condition?

  • A. Dependent rubor.
  • B. Absence of hair on the lower legs.
  • C. Shiny, thin skin on the legs.
  • D. Pain in the legs when walking.
Correct Answer: D

Rationale: Pain in the legs when walking (D), known as intermittent claudication, is most indicative of peripheral arterial disease (PAD). While dependent rubor (A), absence of hair (B), and shiny, thin skin (C) are also associated with PAD, they are less specific than intermittent claudication. Intermittent claudication is a hallmark symptom of PAD caused by inadequate blood flow to the legs during exercise, resulting in pain that resolves with rest.

A client is admitted with a diagnosis of acute pancreatitis. Which assessment finding is most indicative of this diagnosis?

  • A. Epigastric pain that radiates to the back.
  • B. Abdominal pain with guarding.
  • C. Nausea and vomiting.
  • D. Increased bowel sounds in all quadrants.
Correct Answer: A

Rationale: Epigastric pain that radiates to the back (A) is the hallmark assessment finding of acute pancreatitis. The pancreas lies retroperitoneally in the upper abdomen, so inflammation often causes severe epigastric pain that radiates through to the back. Abdominal pain with guarding (B), nausea and vomiting (C), and increased bowel sounds (D) can also be present in acute pancreatitis but are less specific and may be seen in various other gastrointestinal conditions.

A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most beneficial?

  • A. Ask the wife how she would like to participate in the client's care.
  • B. Provide the wife with information about hospice.
  • C. Encourage the wife to visit during and after painful treatments are completed.
  • D. Refer the wife to a support group for family members of those dying of cancer.
Correct Answer: A

Rationale: During this difficult time of coping with terminal cancer diagnosis, involving the wife in the care process can help her feel more in control and connected. This can be beneficial for both the client and his wife, as it fosters a collaborative approach to care and ensures the wife's needs and preferences are considered.

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