HESI FUNDAMENTALS EXAM SPRING 2023 TEST BANK 400 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+

HESI FUNDAMENTALS EXAM SPRING 2023 TEST

BANK 400 QUESTIONS AND CORRECT DETAILED

ANSWERS WITH RATIONALES (VERIFIED ANSWERS)

|ALREADY GRADED A+

The nurse is administering an intermittent infusion of an antibiotic to a client

whose intravenous (IV) access is an antecubital saline lock. After the nurse opens

the roller clamp on the IV tubing, the alarm on the infusion pump indicates an

obstruction. What action should the nurse take first?

Check for a blood return.

Reposition the client's arm.

Remove the IV site dressing.

Flush the lock with saline. - ANSWER- B

Rationale; If the client's elbow is bent, the IV may be unable to infuse, resulting in

an obstruction alarm, so the nurse should first attempt to reposition the client's arm

to alleviate any obstruction (B). After other sources of occlusion are eliminated,

the nurse may need to check for a blood return (A), remove the dressing (C), or

flush the saline lock (D) and then resume the intermittent infusion.

A 35-year-old female client with cancer refuses to allow the nurse to insert an IV

for a scheduled chemotherapy treatment, and states that she is ready to go home to

die. What intervention should the nurse initiate?

Review the client's medical record for an advance directive.

Determine if a do-not-resuscitate prescription has been obtained.

Document that the client is being discharged against medical advice.

Evaluate the client's mental status for competence to refuse treatment. - ANSWERD

Rationale; Competent clients have the right to refuse treatment, so the nurse

should first ensure that the client is competent (D). (A and C) are not necessary for

a competent client to refuse treatment. The nurse cannot document (C) until the

healthcare provider is notified of the client's wishes and a discharge prescription is

obtained.

A client in hospice care develops audible gurgling sounds on inspiration. Which

nursing action has the highest priority?

Ensure cultural customs are observed.

Increase oxygen flow to 4L/minute.

Auscultate bilateral lung fields.

Inform the family that death is imminent. - ANSWER- D

Rationale; An audible gurgling sound produced by a dying client is characteristic

of ineffective clearance of secretions from the lungs or upper airways, causing a

"rattling" sound as air moves through the accumulated fluid. The nursing priority

in this situation is to convey to the family that the client's death is imminent (D).

Although culturally sensitive care should be observed throughout the client's plan

of care (A), this is not the priority at this time. Administration of oxygen may be

expected care, but a flow rate greater than 2 L/minute (B) is not palliative care. (C)

may provide additional information, but is not necessary as death approaches.

A signed consent form indicated a client should have an electromyogram, but a

myelogram was performed instead. Though the myelogram revealed the cause of

the client's back pain, which was subsequently treated, the client filed a lawsuit

against the nurse and healthcare provider for performing the incorrect procedure.

The court is likely to rule in favor of the plaintiff because these events represent

what infraction?

A quasi-intentional tort because a similar mistake can happen to anyone.

Failure to respect client autonomy to choose based on intentional tort law.

Assault and battery with deliberate intent to deviate from the consent form.

An unintentional tort because the client benefited from having the myelogram. -

ANSWER- C

Rationale; The client was not properly informed of the procedure, and failure to

obtain informed consent constitutes assault and battery (C). (A) is injury to

economics and dignity, such as invasion of privacy or defamation of character.

This is not an incident of failure to respect the client's autonomy (B). An

unintentional tort (D) is an act in which the outcome was not expected, such as

negligence or malpractice.

The nurse formulates the nursing diagnosis of, "Ineffective health maintenance

related to lack of motivation" for a client with Type 2 diabetes. Which finding

supports this nursing diagnosis?

Does not check capillary blood glucose as directed.

Occasionally forgets to take daily prescribed medication.

Cannot identify signs or symptoms of high and low blood glucose.

Eats anything and does not think diet makes a difference in health. - ANSWER- D

Rationale; The nursing diagnosis of ineffective health maintenance refers to an

inability to identify, manage, and/or seek out help to maintain health, and is best

exemplified in the client belief or understanding about diet and health

maintainance (D). (A) indicates noncompliance with an action to be done in the

management of diabetes. (B) represents inattentiveness. (C) reflects knowledge

deficit.

In evaluating client care, which action should the nurse take first?

Determine if the expected outcomes of care were achieved.

Review the rationales used as the basis of nursing actions.

Document the care plan goals that were successfully met.

Prioritize interventions to be added to the client's plan of care. - ANSWER-