a cva stroke patient goes into respiratory distress and is placed on a ventilator the clients daughter arrives with a durable power of attorney and a
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Nursing Elites

HESI RN

HESI Fundamentals Practice Test

1. A CVA (stroke) patient goes into respiratory distress and is placed on a ventilator. The client’s daughter arrives with a durable power of attorney and a living will that indicates there should be no extraordinary life-saving measures. What action should the nurse take?

Correct answer: B

Rationale: In this situation, the nurse should notify the healthcare provider. The healthcare provider needs to be informed to review the legal documents provided by the patient's daughter, such as the durable power of attorney and living will, which specify the patient's wishes regarding life-saving measures. The healthcare provider will be responsible for making the appropriate decision based on the legal documents and the patient's current condition. Referring to the risk manager (choice A) is not necessary as the issue at hand pertains to the patient's medical care. Discontinuing the ventilator (choice C) without healthcare provider input could go against the patient's wishes and legal documents. Reviewing the medical record (choice D) may not provide immediate guidance on the current situation and the patient's preferences regarding life-saving measures.

2. The healthcare provider is conducting an initial admission assessment for a woman who is Mexican-American and who is scheduled to deliver a baby by C-section in the next 24 hours. What should the healthcare provider include in the assessment?

Correct answer: D

Rationale: When caring for patients from diverse cultural backgrounds, it is essential to respect and consider their cultural norms and practices while providing healthcare. Understanding and incorporating cultural beliefs and values can enhance the quality of care and improve patient outcomes.

3. The health care provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication?

Correct answer: B

Rationale: When a medication is administered via the IV route, the absorptive process is bypassed, leading to a more rapid onset of action. This results in a faster effect of the drug. Choice A is incorrect because changing the route of administration does not necessarily lead to increased tolerance or the need for a higher dose. Choice C is incorrect as changing the route of administration does not directly affect the protein binding of a medication. Choice D is incorrect because increasing the therapeutic index would actually reduce the risk of toxicity, not increase it.

4. A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs?

Correct answer: B

Rationale: The correct answer is B. In the Jehovah's Witness religion, blood transfusions are forbidden due to their beliefs. Autopsy prohibition is in Judaism, while alcohol and drug use is not allowed in Buddhism. While some sects are vegetarian, the critical concern in nursing care for Jehovah's Witnesses is respecting their prohibition of blood transfusions.

5. When assisting an older adult client in preparing to take a tub bath, which nursing action is most important?

Correct answer: A

Rationale: The most crucial nursing action when assisting an older adult client with a tub bath is to check the bath water temperature. This step is essential to prevent burns from hot water or chilling from water that is too cold. Ensuring the water temperature is safe is a critical aspect of promoting the client's safety and comfort during the bathing process.

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