an older adult who recently began self administration of insulin calls the nurse daily to review the steps that should be taken when giving an injecti

HESI RN

HESI Fundamentals Quizlet

1. An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client is capable of giving the daily injection. Which response by the nurse is likely to be most helpful in encouraging the client to assume total responsibility for the daily injections?

A. I know you are capable of giving yourself the insulin.
B. Giving yourself the injection seems to make you nervous.
C. When I watched you give yourself the injection, you did it correctly.
D. Tell me what you want me to do to help you give yourself the injection at home.

Correct answer: C

Rationale: Choice C is the correct answer because focusing on the client's demonstrated ability to self-administer the injection is likely to reinforce his level of competence without sounding punitive. By acknowledging the client's correct performance during the self-injection, the nurse can boost the client's confidence, encouraging him to assume total responsibility for the daily injections. Choices A, B, and D do not directly highlight the client's competence in self-administration, which may not be as effective in promoting independent self-care.

2. When caring for a client with a chest tube, which intervention is most important?

A. Keep the drainage system at chest level.
B. Ensure that the chest tube is clamped at all times.
C. Strip the chest tube every shift.
D. Ensure that the chest tube is connected to a water-seal drainage system.

Correct answer: D

Rationale: The most crucial intervention when caring for a client with a chest tube is to ensure that the chest tube is connected to a water-seal drainage system (D). This system helps maintain proper lung expansion and prevents complications. Keeping the drainage system at chest level (A) is important to facilitate drainage, but not as critical as ensuring the connection to the drainage system. Clamping the chest tube (B) is unnecessary and can lead to serious issues. Stripping the chest tube (C) is an outdated practice and can cause harm rather than benefit.

3. A client with a diagnosis of coronary artery disease is receiving atorvastatin (Lipitor). Which laboratory test should the nurse monitor to evaluate the effectiveness of this medication?

A. Complete blood count (CBC)
B. Serum potassium level
C. Liver function tests (LFTs)
D. Serum cholesterol level

Correct answer: C

Rationale: To evaluate the effectiveness of atorvastatin (Lipitor), the nurse should monitor liver function tests (LFTs) (C) because this medication can impact liver function. Complete blood count (CBC) (A), serum potassium level (B), and serum cholesterol level (D) are not directly indicative of the medication's effectiveness in managing coronary artery disease.

4. While suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?

A. Suction deeper to remove secretions.
B. Gently withdraw suction tubing to allow suction or coughing out of mucus.
C. Remove the suction as quickly as possible.
D. Insert and remove the suction multiple times to clear secretions.

Correct answer: B

Rationale: When a client coughs during tracheostomy tube suctioning, the nurse should gently withdraw the suction tubing. This action allows the client to cough out mucus naturally, reducing the risk of further irritation and promoting effective airway clearance. Choice A is incorrect because suctioning deeper can cause trauma and increase the risk of complications. Choice C is incorrect as removing the suction quickly may not allow the client to clear the mucus adequately. Choice D is incorrect as inserting and removing the suction multiple times can lead to unnecessary trauma and discomfort for the client.

5. What is the most effective way to implement a teaching plan?

A. Teach the information that the learner wants to learn first.
B. Streamline the teaching plan to include only essential information.
C. Present to the learner all the necessary information to meet the objectives.
D. Provide the learner with written material to review before teaching sessions.

Correct answer: A

Rationale: The most effective way to implement a teaching plan is to teach the information that the learner wants to learn first. Teaching should be learner-centered, responding to the individual's needs and preferences. Learning is most successful when it addresses the specific interests and goals of the learner, as it increases motivation and engagement. By starting with what the learner is interested in, you can create a more effective and engaging learning experience.