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Hesi rn foundation of nursing
Total Questions : 54
Showing 10 questions, Sign in for moreThe client is an 81-year-old female who is in the hospital for treatment of a blood clot. She has a history of type 2 diabetes mellitus and takes metformin. She is active at home and performs activities of daily living independently but has required assistance from her son for the last couple of weeks due to weakness and fatigue. During the night shift, the client was found incontinent of urine twice. She stated, "I just couldn't get to the bathroom in time." The call light was not within reach when the episodes occurred. No signs of urgency or dribbling were noted, and the client is alert and oriented.
Temperature: 36.9°C (98.4°F)
Blood Pressure: 138/82 mmHg
Heart Rate: 88 beats/min
Respiratory Rate: 16 breaths/min
SpOâ‚‚: 97% on room air
Blood glucose: 144 mg/dL (postprandial)
Patient data
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
Potential Condition:
Functional incontinence: This occurs when a person is continent but unable to reach the toilet due to physical limitations, environmental barriers, or cognitive impairment. In this case, the client is physically weak and could not access the bathroom or call for help in time.
Actions to Take:
Secure the call bell so it is within reach: This empowers the client to request assistance promptly, helping to prevent further episodes of incontinence.
Create a toilet training program: Scheduled toileting or prompted voiding assists in managing incontinence related to functional limitations.
Parameters to Monitor:
Episodes of incontinence: Tracking frequency helps assess if interventions are reducing the number of episodes.
Skin integrity: Incontinence increases the risk for skin breakdown, especially in older adults with limited mobility.
Incorrect Potential Conditions:
Overflow urinary incontinence: Involves dribbling due to bladder overdistension, typically from obstruction or weak detrusor muscles—not consistent with this client’s symptoms.
Reflex urinary incontinence: Related to neurological impairment; the client shows no signs of spinal cord injury or neurological disease.
Urge incontinence: Involves sudden urgency with loss of urine before reaching a toilet; not reported by the client.
A client tells the nurse how they hate the way their boss orders them around and never listens to their suggestions. Which response is best for the nurse to provide?
The nurse is teaching the unlicensed assistive personnel (UAP) about safety when caring for clients with limited movement. Which action by the UAP indicates to the nurse that the UAP understands the information?
While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement?
The nurse is caring for a client who is overweight and easily becomes diaphoretic. In response to this finding, which assessment(s) should the nurse include while assisting the client with personal care? Select all that apply.
To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes, but does not feel a pulsation. Which action should the nurse take next?
The healthcare provider prescribes digoxin elixir 125 mcg PO daily. The drug is available in a 60 mL bottle labeled, "Digoxin elixir 0.05 mg/mL. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)
Explanation
Convert the prescribed dose from micrograms (mcg) to milligrams (mg).
Desired dose in mg = Desired dose in mcg / 1000 mcg/mg
= 125 mcg / 1000 mcg/mg
= 0.125 mg.
Available concentration of the digoxin elixir = 0.05 mg/mL.
Calculate the volume in milliliters (mL) to administer.
Volume (mL) = Desired dose (mg) / Available concentration (mg/mL)
= 0.125 mg / 0.05 mg/mL
= 2.5 mL.
A client is being admitted to the unit with a varicella zoster virus infection. Which room should the charge nurse assign to the client?
A client requests heat therapy for lower back pain. Which action should the nurse take?
While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?
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