2019 HESI FUNDAMENTALS RN 47 TEST BANK Q/A
1. Wheezing is often associated with asthma- assess breathing patterns and learn about
any precipitating factors that caused the onset of the wheezing
2. A male client with
...
2019 HESI FUNDAMENTALS RN 47 TEST BANK Q/A
1. Wheezing is often associated with asthma- assess breathing patterns and learn about
any precipitating factors that caused the onset of the wheezing
2. A male client with limited mobility is discharged with home health services. When the
home health nurse arrives, the client asks what he does for the swelling in his leg. Which
should the nurse implement?
✓ -instruct the client to flex both of his feet several times a day
3. A client at an outpatient clinic submits a clean-catch midstream urine specimen for
routine urinalysis. In later review of the client’s medical record, which data indicates to
the nurse that the specimen collection should be repeated?
✓ -the urine specimen shows multiple organisms in low colony counts
Rationale: *often indicates that a contaminated specimen was obtained
4. During the admission assessment of a terminally ill male client, the client states that he
is an agnostic. What is the best nursing action in response to this statement?
✓ -document the statement in the client’s spiritual assessment
5. The nurse observes a newly admitted older adult female take short stems and walk very
slowly while pushing a walker in front of her. What action should the nurse take in
response to these observations?
✓ -complete a full fall risk assessment of the client
6. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital signs
should the nurse obtain first?
✓ -respiratory rate
Rationale: *cyanosis is a bluish discoloration, an indication of hypoxemia
7. A middle-aged male client tells the nurse that two weeks ago, he began exercising four
times a week to lose weight and to help him sleep better. He states that it still takes him
an hour to fall asleep at night. Which action should the nurse implement?
✓ -ask the client to describe the exercise schedule that he has been following
Rationale: *to determine if he is exercising too close to bedtime
8. While suctioning a client's nasopharynx, the nurse observes that the patient's oxygen
saturation remains at 94%, which is the same reading obtained before starting the
procedure. What action should the nurse take in response to this finding?
✓ -complete the intermittent suction of nasopharynx *suctioning can be
continued if the client’s oxygen saturation remains above 90% or does not
decrease 5% from the initial baseline
9. An older male client returns to the clinic for chronic pain management after taking
morphine sulfate (MS Contin) 25 mg every 12 hours. He states he took the medication
only when the pain was too severe to sleep. What action should the nurse implement?
✓ -instruct the client to take the MS Contin every 12 hours as prescribed
10. A female, unlicensed assistive personnel (UAP) is assigned to take the vital signs of a
client with pertussis for whom droplet precautions have been implemented. The UAP
requests a change in assignment, stating she has not yet been fitted for a particulate
filter mask. What action should the nurse take first?
✓ -instruct the UAP that a standard face mask is sufficient for the provision of care
for the assigned client
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