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
...
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
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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?
This study source was downloaded by 100000835004878 from CourseHero.com on 04-07-2022 00:23:15 GMT -05:00
https://www.coursehero.com/file/122923280/HESI-RN-2019-HESI-Fundamen
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