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HESI RN Foundation of Nursing
HESI RN Foundation of Nursing
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Review was done of H and P, nurses' notes, and orders.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Explanation
Pressure sores are divided into different stages:
Stage 1= Intact skin with non-blanchable redness over a localized area
Stage 2= Partial thickness loss of dermis, shallow open ulcer with a pink base
Stage 3= Full thickness ulcer but tendons, muscles and bone are not exposed
Stage 4- Full thickness wound with exposed tendons, muscle and bone
Unstageable-Full thickness tissue loss with the base covered with an eschar or yellow, gray or brown tissue
The client already has a pressure sore that requires cleaning to remove any tissue debris that may act as nidus for infection, placing a hydrocolloid dressing protects and debrides the wound to promote healing Monitoring skin integrity is key to ensure no other pressure sores develop.
Nutritional status determines the risk of developing pressure injury and the chances of wound healing.
A nurse stops at a motor vehicle collision to provide help for a victim who is trapped in an overturned running vehicle. The nurse turns off the engine key, and asks the client to wiggle the fingers because the client's head is impinged on the roof and the neck is bent to the left shoulder. After Emergency Medical Services (EMS) arrive, the nurse reports that the victim is conscious, but is not able to talk, and then the nurse leaves the scene. Which legal action can be taken in this situation?
Explanation
A. Assault and battery involve intentional harmful or offensive contact with another person without their consent. Criminal assault is the threat of harm, while battery is the actual physical contact.
In this scenario, the nurse's actions were aimed at providing assistance to the victim, not causing harm. Therefore, criminal assault and battery would not apply.
B. Good Samaritan immunity protects individuals who provide assistance in emergency situations from liability for any injuries or damages that may occur as a result of their actions, as long as they act in good faith and without expectation of compensation. In this scenario, the nurse stopped to provide assistance voluntarily and acted in the victim's best interest. Good Samaritan immunity would likely apply in this situation, protecting the nurse from liability for any unintended consequences of their actions.
C. In this scenario, if the nurse failed to provide necessary care or took actions that deviated from the standard of care expected in similar circumstances, it could be considered negligent. However, the specific concern in this scenario is more aligned with abandonment of the victim rather than negligent acts of omission.
D. Abandonment occurs when a healthcare provider discontinues care without ensuring that the patient's needs are met or transferring care to another qualified individual. In this scenario, the nurse reported the victim's condition to EMS before leaving the scene. The nurse did not abandon the victim as they ensured that the victim received ongoing care from EMS.
The nurse is assessing a client who reports a 3 day history of vomiting and diarrhea and experiencing difficulty in tolerating oral fluids. Which urine specific gravity value would the nurse expect to see on initial testing?
Reference Range:
Urine Specific Gravity [1.005 to 1.03]
Explanation
B. When assessing urine specific gravity, which measures the concentration of solutes in urine, it's expected to be elevated in cases of dehydration.
A. This value falls within the normal reference range for urine specific gravity (1.005 to 1.03).
A urine specific gravity of 1.025 indicates normal concentration of solutes in the urine, which would be expected in a well-hydrated individual.
C. This value falls within the normal reference range for urine specific gravity (1.005 to 1.03).
A urine specific gravity of 1.005 indicates low concentration of solutes in the urine, which would not be expected in a dehydrated individual.
D. This value falls within the normal reference range for urine specific gravity (1.005 to 1.03).
A urine specific gravity of 1.015 indicates normal concentration of solutes in the urine, which would be expected in a well-hydrated individual.
The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?
Explanation
D. The Situation, Background, Assessment, and Recommendation (SBAR) format of communication is commonly used in healthcare settings to facilitate effective and concise communication, especially when reporting critical information.
A. While effective communication is essential during discharge teaching to ensure that the client and family members understand the instructions and follow-up care, the SBAR format is not typically used in this context.
B. When offering therapeutic support and comfort to a grieving family, the focus is on empathy, active listening, and providing emotional support.
C. When obtaining clarification from a client's healthcare power-of-attorney, it's important to ensure that information is communicated accurately and any questions or concerns are addressed.
An unlicensed assistive personnel (UAP) is assigned to feed a client who has received a prescription to institute droplet precautions for a bacterial meningitis infection. The UAP requests a change in assignment, reporting having not yet been fitted for a particulate filter mask. Which action should the nurse take?
Explanation
A. For meningococcal infections, droplet precautions, including a standard face mask, are recommended for the first 24 hours of antimicrobial therapy.
Instructing the UAP to use a standard face mask may not provide adequate protection against airborne pathogens, potentially putting the UAP and other clients at risk of infection.
B. This option involves gathering information about which staff members have been fitted for particulate filter masks, which is important for ensuring that appropriate protective equipment is available for staff who need it.
C. Taking the client’s vital signs is also an important procedure that requires a particulate filter mask
D. Sending the UAP for an immediate fitting for a particulate filter mask is unnecessary for droplet precautions and could delay essential care for the client.
The nurse is caring for a client one-week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?
Explanation
A. A well-approximated incision site refers to the edges of the surgical incision being closely aligned and in good alignment with minimal separation.
This finding is indicative of proper wound closure and initial stages of healing. It suggests that the wound edges are healing together, which is essential for preventing complications such as infection and promoting optimal wound healing.
B. Beefy red granulation tissue is a sign of the proliferative phase of wound healing. It appears as healthy, pinkish-red tissue that fills in the wound bed.
Granulation tissue consists of new blood vessels, fibroblasts, and connective tissue, and it serves to support wound healing by providing a scaffolding for tissue repair and promoting angiogenesis (formation of new blood vessels).
While the presence of granulation tissue is a positive sign indicating that the wound is progressing through the healing process, it typically occurs later in the healing timeline, beyond the initial one- week post-surgery period.
C. Eschar and slough are non-viable tissue components that can be present in a wound. Eschar is typically dry, black, or brown necrotic tissue, while slough is moist, yellow, or white necrotic tissue.
The presence of eschar and slough in a wound indicates that there is still non-viable tissue present that needs to be removed to facilitate healing.
D. Erythema (redness) and serosanguineous exudate (clear to blood-tinged fluid) are common findings in the early inflammatory phase of wound healing.
While some degree of erythema and serosanguineous exudate may be expected in the immediate postoperative period, especially within the first few days, persistent or increasing erythema and exudate beyond one week post-surgery may indicate inflammation or infection.
A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?
Explanation
A. Reviewing the advance directive is important but not the immediate priority in an acute situation.
B. Irrigating the nasogastric (NG) tube with water is not the priority action in this scenario.
C. Elevating the head does no address teh client's concern of choking and risk of apiration,
D. Performing oropharyngeal suctioning prevents aspiration of gastric content into the airway
A client with chronic fecal incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?
Explanation
B. Assisting the client to a bedside commode after meals can help take advantage of the gastrocolic reflex, which typically stimulates bowel movements after eating. This timing may increase the likelihood of successful bowel evacuation and decrease the risk of soiling the bed and clothing.
A. Rectal tubes are sometimes used for bowel management in individuals with chronic fecal incontinence, but they are typically reserved for specific situations and are not commonly used as part of a routine bowel training regimen.
C. Glycerin suppositories are sometimes used to stimulate bowel movements in individuals with constipation, but they are not typically recommended as a routine intervention for managing fecal incontinence.
D. Incontinence briefs can help contain fecal soiling and minimize embarrassment associated with accidents but they do not address the underlying issues contributing to fecal incontinence.
The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?
Explanation
A. Encouraging the client to visualize positive external places, such as peaceful landscapes, serene beaches, or tranquil gardens, can help distract from the pain and promote relaxation. This focus can help shift the client's attention away from the pain sensation, potentially reducing its intensity and improving overall comfort.
B. Tranquil sounds can be utilized but are not a form of guided imagery.
C. Emotional reflection (choice C) may not directly contribute to pain relief during guided imagery sessions.
D. Incorporating motivational phrases during guided imagery can help boost the client's mood, enhance self-confidence, and foster a positive mindset, which may contribute to pain relief and overall well- being. However, positive external places should be the primary focus.
Patient Data
The primary nurse went on break at 1845. The covering nurse gave insulin glargine and decided to manually document the dose but forgot to enter it into the electronic health record. The primary nurse came back from break and gave a second dose of insulin because of being unaware the covering nurse gave the ordered dose.
What medication error prevention techniques would have helped to avoid this error? Select all that apply.
Explanation
Immediate documentation after drug administration ensures the everyone who comes into contact with the client is aware of what has already been done
Ensuring the client does the administration also avoids such errors. The client is able to understand and question when too many doses are given without proper explanation.
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