Hesi Foundations

provider prescribes bladder irrigation to maintain patency of client's indwelling urinary catheter. Intervention?

Which technique is most important for the nurse to implement when performing a physical assessment?

home nurse is teaching client how to change dressing on a new ulcer. Removing bandages, she observes redness. Action?

providing passive ROM exercises to hip and knee for client supporting the client's knee with one hand. Action next?

lithium, has a narrow therapeutic index. Which adverse effect is most important for the nurse include in teaching plan?

While interviewing a client, the nurse records the assessment in the electronic health record. Which is most accurate?

Nurse observes that suctioning nasopharynx, o2 remains @ 94%, same as when she started.What action does she take?

The UAP described the appearance of bowel movement of clients. What description warrant additional follow up?

24-hour urine collection client tells nurse that the last voiding accidentally flushed instead of saved. Intervention?

client has a serum sodium level of 123 mEq/L. What question should the nurse ask this client?

discharged to a long-term care facility with indwelling urinary catheter. What should be included to reduce uti?

feeding elderly male client who is debilitated but is able to respond to commands. Obtain what before starting?

client is in contact isolation due to MRSA. The nurse plans interventions to prevent multiple reentries. Correct order?

evaluating effectiveness of a client's nursing care,first review expected outcomes identified in the plan of care. Next?

client informs nurse that she uses herbal therapies. What information should nurse offer client about use of herbs?

Which is example of a correctly written nursing diagnosis?Altered tissue perfusion R/T congestive heart failure

grandmother of pt admitted to psychiatric unit yesterday requests info about her grandson's treatment plan. action?

Client taking 3 analgesics. Nurse adminsters dose that is not within prescribed parameters. What action does she take?

nurse reviews personal care of an client who lives alone. Which findings indicate the need to assign routine foot care?

Which patient should be closely monitored for sleep apnea?

A client w/ limited mobility is discharged with home care. The client asks what he can do for the swelling in his legs.

client has pneumonia & recent history of MRSA & placed in isolation. which item should be placed in biohazard bag?

Client in outpatient clinic complains of experiencing hard infrequent stools. Which instruction should the nurse provide

performing blood pressure measurement assessing for orthostatic hypotension. Which action should nurse implement first?

2 nurses assess a pulse deficit & count apical pulse of 72 beats/minute and radial pulse of 88 beats/minute. Action?

Lady with end-stage heart disease is hospitalized. She is alert, oriented, & requests that no heroic measurures. Action

student admits to smoking 10 to 15 cigarettes daily. Convinced he is addicted. Which intervention is best?

man began exercising to lose weight & help him sleep better. He is still having trouble sleeping. Action to implement?

client who has been taking diuretics for premenstrual swelling reports muscle weakness. Report to doctor which value?

administering infusion of antibiotic client whose IV access is antecubital saline lock. There is obstruction.. action?

The CNA is in room cleaning butt of c-diff Pt states client has diarrhea and only wearing gloves. Action by nurse?

nurse measures client's blood pressure and notes that it is significantly higher than previous reading. what's next?

Client diagnosed with terminal cancer tells nurse, "doc told me I have cancer and do not have long to live." Response?

female client is one day post mastectomy is crying when nurse enters the room. What action should the nurse take?

What information is most important for nurse to obtain in determining a client's need for referral of obesity counseling

male presents to clinic and states that he has chronic constipation and has tried home remedies. Which intervention?

What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile?

It is most important for a nurse to recalculate a patient's Braden score who develops which problem?

client on full liquid diet has diagnosis, Risk for impaired skin integrity related to reduced oral intake. Best snack?

What self-care outcome best to use in evaluating client's recovery from stroke that resulted in left-sided hemiparesis?

Nursing home resident & family only speak Spanish. During visit family begins to cry. what intervention most important

reviewing the admission assessment of client with chronic pain, which interventions should include in this client's plan

stage 4 pressure ulce has black, hardened surface & light pink wound bed w/ malodorous green drainage. which dressing?

preparing to irrigate client's indwelling urinary catheter using an open technique. What action after applying gloves?

Which assessment finding is most significant in determining the level of assistance client requires with personal care?

caring for client who washes feet but can't bend & dry them. Nurse should emphasize need to dry which part of his feet?

Prior to attempting a digital removal of a fecal impaction, it is most important to perform which assessment?

Which action should the nurse implement when using the confrontation technique during a vision exam?

Elderly comes in due to vaginal bleeding, tear is due to unprotected sex. What do you include in client's care plan?

When caring for an immobile client, what nursing diagnosis has the highest priority?

confused elderly client is having trouble sleeping at night & sometimes found wondering in the hallway. Intervention

Client w/ limited tolerance for activity needs to walk in hallway w/ help. What instructions should nurse give to UAP?

A client diagnosed with open-angle glaucoma received a prescription for drops. What should be included in plan of care?