after the nurse tells an older client that an iv line needs to be inserted the client becomes very apprehensive loudly verbalizing a dislike for all h
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Nursing Elites

HESI RN

HESI Quizlet Fundamentals

1. After informing an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly expressing a dislike for all healthcare providers and nurses. How should the nurse respond?

Correct answer: C

Rationale: In this situation, the nurse should respond by calmly reassuring the client that the discomfort from the IV insertion will be temporary. By providing reassurance and addressing the client's concerns, the nurse can help reduce the client's apprehension and create a more supportive environment for the procedure.

2. A client is admitted with a diagnosis of acute pancreatitis. Which assessment finding is most indicative of this diagnosis?

Correct answer: A

Rationale: Epigastric pain that radiates to the back (A) is the hallmark assessment finding of acute pancreatitis. The pancreas lies retroperitoneally in the upper abdomen, so inflammation often causes severe epigastric pain that radiates through to the back. While abdominal pain with guarding (B), nausea and vomiting (C), and increased bowel sounds (D) can also be present in acute pancreatitis, they are less specific and may be seen in various other gastrointestinal conditions. Therefore, the most indicative finding for acute pancreatitis is epigastric pain that radiates to the back.

3. During a home visit, an elderly female client who had a brain attack three months ago and can now ambulate with a quad cane is assessed by the nurse. Which assessment finding has the greatest implications for this client's care?

Correct answer: C

Rationale: The presence of numerous scatter rugs throughout the house poses a significant safety hazard to the client who is ambulating with a quad cane. These rugs increase the risk of tripping and falling, making it the most critical finding that needs immediate attention to prevent potential injuries and ensure the client's safety during ambulation.

4. 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.

5. A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best?

Correct answer: A

Rationale: The best action for the nurse is to determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. By incorporating familiar bedtime rituals that do not compromise the client's safety, the nurse can help the client fall asleep faster and improve the overall quality of care provided to the client.

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