the nurse is providing passive range of motion rom exercises to the hip and knee for a client who is unconscious after supporting the clients knee wit
Logo

Nursing Elites

HESI RN

HESI Quizlet Fundamentals

1. The healthcare provider is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the healthcare provider take next?

Correct answer: D

Rationale: When providing passive ROM exercises to the hip and knee for an unconscious client, it is essential to support the joints of the knee and ankle. The next action should be to cradle the client's heel and gently move the limb in a slow, smooth, firm, but gentle manner. This helps maintain joint mobility and prevent contractures.

2. When caring for an older incontinent client at risk for infection, which intervention is best for the nurse to implement based on the nursing diagnosis of risk for infection?

Correct answer: A

Rationale: The correct intervention for an older incontinent client at risk for infection is to maintain standard precautions. Standard precautions, which include proper handwashing, are essential in reducing the risk of infection transmission in vulnerable clients. Initiating contact isolation measures may not be necessary for all clients, and inserting an indwelling urinary catheter should be avoided unless medically necessary to prevent additional risks of infection. Instructing the client in the use of adult diapers is not an appropriate nursing intervention to prevent infection.

3. You are assigned to teach a student how to suction an adult patient with a tracheostomy. Which of the following actions by the student would be incorrect?

Correct answer: D

Rationale: The incorrect action by the student is applying gentle intermittent pressure and rotating the catheter during the insertion phase of suctioning. This technique can cause trauma to the tracheal walls, increasing the risk of injury to the patient. It is essential to perform suctioning gently and without rotation to prevent complications in patients with a tracheostomy. Pre-oxygenating the patient, maintaining appropriate suction pressure, and limiting suctioning time are all correct actions when suctioning a patient with a tracheostomy.

4. The healthcare provider receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 6-hour shift. Which intervention should the healthcare provider implement first?

Correct answer: A

Rationale: The first intervention should be to check the drainage tubing for a kink. This step is crucial as any kinks in the tubing could obstruct urine flow, leading to a decreased output. By ensuring the tubing is free from any obstructions, the healthcare provider can address a potential mechanical issue causing the low output before considering other interventions. Reviewing the intake and output record may provide valuable information but should come after ensuring the tubing is clear. Notifying the healthcare provider can be done later if needed, but the immediate concern is to check for any obstructions. Giving the client water to drink may be necessary depending on the assessment findings, but addressing a possible kink in the tubing takes precedence.

5. A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?

Correct answer: D

Rationale: The correct action for the nurse to take first in this situation is to compare the current blood pressure reading with the client's previously documented readings. This comparison will provide valuable information about what is normal for this specific client, helping to determine if the current reading represents a significant change or if it falls within the client's usual range. By reviewing the client's past readings, the nurse can assess trends, variations, and if the current reading is an isolated high value or part of a pattern, guiding appropriate decision-making. Informing the client about the high reading (Choice A) or contacting the healthcare provider for medication (Choice B) should come after assessing the client's history. Replacing the cuff (Choice C) is not necessary at this point and does not address the immediate need to compare the readings for appropriate intervention.

Similar Questions

When a male client mentions his foot is hurting while watching TV with his wife, how should the nurse respond?
To avoid nerve injury, what location should the nurse select to administer a 3 mL IM injection?
The healthcare provider is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?
A client is admitted with a diagnosis of heart failure. Which dietary instruction should the nurse provide?
During the assessment, a client receiving a continuous infusion of heparin for deep vein thrombosis (DVT) is found to have a nosebleed. Which finding requires immediate action?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses