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HESI FUNDAMENTALS PRACTICE TEST / FINAL EXAM 1 (NCLEX)

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HESI FUNDAMENTALS PRACTICE TEST / FINAL EXAM 1 (NCLEX) A 35y/o client with cancer refuses to allow a nurse to insert an IV for scheduled chemo & states that she's ready to go home to die. What inte ... rvention should the nurse initiate? - Evaluate the client's mental status for competence to refuse treatment Rationale: Competent clients have the right to refuse treatment. The nurse cannot document until the HCP is notified of the patient's wishes & a d/c RX is obtained. Advance directives & DNR are not necessary for competent client to refuse care. A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates client's protein status for the longest length of time? - Serum albumin Rationale: Serum albumin has a long half-life. What client statement indicates to the nurse that the client requires assistance with bathing? - "I don't understand why I'm so weak & tired." How should the nurse handle linens that are soiled with incontinent feces? - Place the soiled linens in a pillow case & deposit them in the dirty linen hamper When caring for an immobile client, what nursing diagnosis has the highest priority? - Impaired gas exchange The nurse assesses an immobile, elderly male client & determines that his blood pressure is 138/60, his temperature is 95.8F & his output is 100 mL of concentrated urine during the last hour. He has wet sounding lungs & increased respiratory secretions. Based on these assessment findings , what nursing action is most important for the nurse to implement? - Turn the client q2h Rationale: It will help move & drain respiratory secretions & prevent pneumonia from occurring. [Show More]

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