HESI RN EXIT > EXAM > HESI RN FUNDAMENTALS EXIT REAL 2025/2026 EXAM NEWEST WITH 100 STUDY QUESTIONS WITH CORRECT VERIFIED (All)
HESI RN FUNDAMENTALS EXIT REAL 2025/2026 EXAM NEWEST WITH 100 STUDY QUESTIONS WITH CORRECT VERIFIED ANSWERS WITH RATIOANLES GUARANTEED PASS | RATED A+
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The nurse is providing care to a client who had major abdominal surgery. Upon return from the recovery room, the client's vital signs were at the pre-operative baseline. The client was sleepy, but aro... usable, and the skin was warm and dry to the touch. At the 1 hour post admission assessment the nurse notes: heart rate 120 and thready, B/P 70/40 mm Hg, and the skin is cool and clammy to the touch. What are the priority nursing actions? (Select all that apply.) A. Call the health care provider. B. Elevate the head of the bed. C. Observe for restlessness/confusion. D. Administer oxygen by re-breather mask. E. Observe the abdominal bandage. - Answer>>> A, C, D, E Rationale: The client's is showing signs of hemorrhagic shock. This is a medical emergency. The head of bed may need to be lowered or placed in Trendelenburg position to increase circulation to the brain. The remaining selections are correct. The nurse is providing care to an 86-year-old admitted for a heart catheterization. The nurse determines the client does not have an advance directive (AD) on file. What are the nurse's next steps? (Select all that apply.) A. Ask the client's cardiologist to come to the hospital and obtain the AD. B. Ask the client, "Have you considered completing the paperwork for an AD?" C. Ask the client's spouse to complete the AD. D. Tell the client, "An AD helps the staff provide care according to your wishes." E. Call the client's clergy member to make the final decisions for the client. - Answer>>> B, D Rationale: A living will is one type of advance directive. The living will outlines the medical treatment the client elects in the event that the client is no longer able to participate in the decision-making process. As long as the client has capacity, the client is the sole determinant for the AD. While a living will describes the wishes of the client, it does not have to be obtained from the physician. Clients may be assisted by the social work staff. The forms can be completed outside of a medical facility and it is the client's responsibility to provide a copy of the AD to all health care providers. The nurse teaches the use of a gait belt to a caregiver whose spouse has right-sided weakness and needs assistance with ambulation. The caregiver performs a return demonstration of the skill. Which observation indicates that the caregiver has learned how to use the belt? A. Standing on the spouse's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed. B. Standing on the spouse's weak side, the caregiver provides security by holding the gait belt from the back. C. Standing behind the spouse, the caregiver provides balance by holding both sides of the gait belt. D. Standing slightly in front and to the right of the spouse, the caregiver guides the client forward by gently pulling on the gait belt. - Answer>>> B Rationale: The spouse is most likely to lean toward the weak side and needs extra support on that side and from the back to prevent falling. Options A, C, and D provide less security. [Show More]
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