HESI RN
HESI Quizlet Fundamentals
1. A client with stage 4 lung cancer receiving in-home hospice care expresses concerns about pain while the nurse is arranging for discharge. What action should the nurse take?
- A. Explain the potential respiratory issues associated with morphine use.
- B. Educate the family on assessing the effectiveness of analgesics.
- C. Suggest requesting a patient-controlled analgesic (PCA) pump from the healthcare provider.
- D. Provide the client with a schedule for around-the-clock prescribed analgesic use.
Correct answer: D
Rationale: In managing pain for a client with stage 4 lung cancer in hospice care, providing a schedule for around-the-clock prescribed analgesic use is essential. This approach ensures continuous pain control and helps prevent breakthrough pain. By having a consistent dosing schedule, the client can maintain a more stable level of pain relief, enhancing their comfort and quality of life during this critical time.
2. The healthcare provider is providing wound care to a client with a stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states 'clean the wound and then apply collagenase.' Collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the healthcare provider use to cleanse the pressure ulcer?
- A. Lightly coat the wound with povidone-iodine solution
- B. Irrigate the wound with sterile normal saline
- C. Flush the wound with sterile hydrogen peroxide
- D. Remove the eschar with a wet-to-dry dressing
Correct answer: B
Rationale: The correct technique to cleanse a wound when the prescription does not specify a cleaning method is to irrigate the wound with sterile normal saline. Sterile normal saline is the preferred solution for wound cleaning as it is gentle and does not damage healthy tissues. It helps in removing debris and maintaining a moist environment conducive to healing. Povidone-iodine solution and hydrogen peroxide can be harsh on tissues and delay wound healing. Removing eschar with a wet-to-dry dressing is a mechanical debridement method and should not be done without proper assessment and healthcare provider's order.
3. Which client is most likely to be at risk for spiritual distress?
- A. Roman Catholic woman considering an abortion
- B. Jewish man considering hospice care for his wife
- C. Seventh-day Adventist in need of a blood transfusion
- D. Muslim man in need of a total knee replacement
Correct answer: A
Rationale: The correct answer is A. In Roman Catholicism, abortion is strictly prohibited, so a Roman Catholic woman considering this procedure may experience spiritual distress due to conflicts with her religious beliefs. This conflict can lead to emotional and psychological turmoil, affecting her spiritual well-being. It is essential for healthcare providers to recognize and address such conflicts with sensitivity and understanding to provide holistic care.
4. A client in the early stages of Alzheimer’s disease is very anxious and frequently asks about her deceased parents. Which intervention should the nurse implement to reduce the client’s anxiety?
- A. Remind the client that her parents have passed away
- B. Ask the client about her favorite memories with her parents
- C. Engage the client in an activity to distract her from thinking about her parents
- D. Reorient the client to the present reality and surroundings
Correct answer: C
Rationale: Engaging the client in an activity to distract her from thinking about her deceased parents is the most appropriate intervention to reduce anxiety. This approach helps shift the focus away from distressing thoughts and can provide comfort and a sense of calm to the client.
5. The nurse is preparing a client for surgery. What action is most important for the nurse to take?
- A. Ensure that the client signs the consent form.
- B. Review the client's allergies with the surgical team.
- C. Confirm the client's identity using two identifiers.
- D. Verify that the surgical site is marked.
Correct answer: A
Rationale: Ensuring that the client signs the consent form (A) is the most crucial action before surgery. The consent form is legally and ethically necessary for the procedure to proceed. While reviewing allergies (B), confirming identity (C), and verifying the surgical site (D) are essential steps, obtaining the client's informed consent takes precedence to protect the client's rights and ensure a safe surgical experience.
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