twenty minutes after beginning a heat application the client states that the heating pad no longer feels warm enough what is the best response by the
Logo

Nursing Elites

HESI RN

HESI Quizlet Fundamentals

1. Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse?

Correct answer: D

Rationale: Choice (D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. The body's receptors adjust to the constant heat exposure, leading to a decreased sensation of warmth. Choices (A) and (B) provide inaccurate information regarding the situation, while choice (C) is not physiologically sound and could potentially harm the client by increasing the temperature unnecessarily.

2. What action should be taken when adding sterile liquids to a sterile field?

Correct answer: B

Rationale: If a sterile field becomes wet or damp during a procedure, it is considered contaminated as moisture can allow organisms to wick from the surface and compromise the sterility of the field. It is essential to maintain the integrity of the sterile field to prevent infections and ensure patient safety.

3. The nurse is attempting to pass an indwelling catheter in an adult male and is having difficulty. What is the most appropriate action for the nurse?

Correct answer: D

Rationale: If resistance is encountered, the nurse should discontinue the procedure and notify the physician, as this may indicate an obstruction.

4. After ensuring correct tube placement, what action should the nurse take next when administering medications through a nasogastric tube (NGT) connected to suction?

Correct answer: B

Rationale: After ensuring the correct placement of the NGT, the nurse should flush the tube with water to prevent any obstructions and ensure proper medication delivery. Flushing the tube is essential before, after, and in between each medication administration. Clamping the tube for 20 minutes should be done after all medications are administered to prevent clogging. Administering medications as prescribed and preparing medications by crushing tablets and dissolving them in sterile water should only be done after the tube has been appropriately flushed to maintain its patency and effectiveness.

5. When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum 'tents' when gently pinched. Which action should the nurse implement?

Correct answer: C

Rationale: When the nurse observes that the client's skin over the sternum 'tents' when gently pinched, it is a classic sign of fluid volume deficit. This finding indicates dehydration and the need to restore the client's fluid volume. Therefore, the appropriate action for the nurse is to continue the planned nursing interventions aimed at addressing the fluid deficit. Choice A is incorrect as jugular vein distention is associated with fluid overload, not deficit. Choice B is incorrect as offering high-protein snacks does not directly address the fluid volume deficit. Choice D is incorrect as the priority is to address the fluid deficit before addressing skin integrity issues.

Similar Questions

The healthcare provider who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the provider take?
The client reports still being unable to sleep a week after learning progressive muscle relaxation techniques. Which action should the nurse take first?
A client is admitted to the hospital with a diagnosis of pneumonia. Which laboratory test result should the nurse monitor to evaluate the client’s respiratory function?
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?
After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond?

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