a male client has a nursing diagnosis of spiritual distress what intervention is best for the nurse to implement when caring for this client
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Nursing Elites

HESI RN

HESI Fundamentals Practice Test

1. A client has a nursing diagnosis of 'spiritual distress.' What intervention is best for the nurse to implement when caring for this client?

Correct answer: D

Rationale: When a client is going through spiritual distress, employing reflective listening techniques is crucial. This method allows the client to voice their concerns and emotions, providing them with a supportive environment to explore their feelings. Options A and B do not directly address the client's spiritual distress and may undermine the client's feelings. While option C involves a chaplain, using reflective listening directly involves the nurse in addressing and supporting the client's spiritual concerns.

2. The healthcare provider attaches a pulse oximeter to a client's fingers and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Correct answer: B

Rationale: Edema in the fingers and hands can impede the proper functioning of the pulse oximeter, leading to a falsely low oxygen saturation reading. Edema alters the transmission of light through the tissues, affecting the accuracy of the measurement. Therefore, the presence of edema in the fingers and hands is the most likely factor contributing to the low oxygen saturation reading of 91%.

3. The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client?

Correct answer: D

Rationale: The correct transfer procedure for an elderly client with left-sided weakness involves moving the chair parallel to the right side of the bed and standing the client on the right foot. Using the stronger side, the right side, for weight-bearing during the transfer is the safest approach to prevent falls or injuries. Placing the chair at a right angle to the bed on the client's left side before moving can lead to poor body mechanics and increase the risk of accidents. Assisting the client to a standing position and having the client pivot to the left are not recommended for a client with left-sided weakness as it can compromise safety and stability during the transfer.

4. Which serum laboratory value should the nurse monitor carefully for a client who has had an NG tube for suctioning for the past week?

Correct answer: D

Rationale: The nurse should carefully monitor serum sodium levels for a client with an NG tube on suction for an extended period due to potential fluid loss and the risk of developing hyponatremia, an electrolyte imbalance. Hyponatremia can occur as a result of continual suctioning leading to fluid loss, making it crucial to monitor sodium levels to prevent complications associated with low sodium levels. Monitoring white blood cell count, albumin, or calcium is not directly related to the impact of NG tube suction on fluid and electrolyte balance, so these values are not the priority in this scenario.

5. The nursing staff in the cardiovascular intensive care unit is creating a continuous quality improvement project on social media that addresses coronary artery disease (CAD). Which action should the nurse implement to protect client privacy?

Correct answer: A

Rationale: To protect client privacy on social media, it is essential to remove any identifying information of clients who participated in the project. This ensures that sensitive information is not disclosed without consent and maintains confidentiality. Choice B is incorrect because while authored content may be legally discoverable, it does not directly relate to protecting client privacy on social media. Choice C is incorrect as it pertains to the credibility of sources, not client privacy. Choice D is also incorrect as it focuses on copyright laws rather than client privacy protection.

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