when caring for an immobile client what nursing diagnosis has the highest priority
Logo

Nursing Elites

HESI RN

HESI Fundamentals Practice Test

1. When caring for an immobile client, what nursing diagnosis has the highest priority?

Correct answer: B

Rationale: When caring for an immobile client, the nursing diagnosis with the highest priority is impaired gas exchange. This is because impaired gas exchange implies difficulty with breathing, which is essential for sustaining life. Adequate oxygenation is crucial for all bodily functions, and any impairment in gas exchange can lead to serious complications, making it the priority nursing diagnosis to address in an immobile client. Choices A, C, and D are important considerations as well when caring for an immobile client, but they are secondary to impaired gas exchange. Risk for fluid volume deficit may occur due to immobility, but ensuring proper gas exchange takes precedence as it directly impacts the client's immediate survival. Risk for impaired skin integrity is a concern in immobile clients but does not pose an immediate threat to life like impaired gas exchange. Altered tissue perfusion is also critical but is usually a consequence of impaired gas exchange, reinforcing the priority of addressing gas exchange first.

2. When preparing to insert an indwelling urinary catheter, the nurse applies sterile gloves and then tests the catheter balloon for patency. What action should the nurse implement next?

Correct answer: D

Rationale: After testing the catheter balloon for patency, the nurse should proceed to apply a sterile lubricant to the end of the catheter. This lubrication helps facilitate the insertion of the catheter smoothly. Placing a sterile drape under the client's buttocks should have been done prior to this step. Discarding the gloves and applying new sterile gloves is not necessary at this point in the procedure. Instructing the client to inhale and exhale slowly is not part of the immediate steps for inserting an indwelling urinary catheter.

3. A male client presents to the clinic stating that he has a high-stress job and is having difficulty falling asleep at night. The client reports having a constant headache and is seeking medication to help him sleep. Which intervention should the nurse implement?

Correct answer: D

Rationale: Teaching coping strategies is an appropriate first intervention for a client experiencing sleep difficulties and stress. It can help manage stress and improve sleep without immediately resorting to medication. By teaching coping strategies, the nurse empowers the client to address the underlying issues contributing to his sleep problems rather than just providing a temporary solution. Referring for a sleep study and neurological follow-up may be considered later if the client's sleep issues persist despite implementing coping strategies. Determining the client’s sleep and activity pattern may be helpful but addressing coping strategies is more beneficial in managing stress-related sleep issues. Obtaining a prescription for the client to take when stressed does not address the root cause of the sleep problem and may lead to dependency on medication rather than promoting long-term solutions.

4. A Native American individual presents to the clinic with complaints of frequent abdominal cramping and nausea. They state that they have chronic constipation and have not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important for the healthcare provider to implement?

Correct answer: C

Rationale: It is crucial to determine which home remedies the individual has tried to avoid interactions with prescribed treatments and consider cultural practices that may influence their healthcare choices. Understanding the home remedies used can provide insights into the individual's health beliefs, preferences, and potential interactions with conventional treatments, allowing for a more holistic approach to their care.

5. The healthcare professional retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM 6 hours PRN for severe pain. How many mL should the healthcare professional administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth)

Correct answer: A

Rationale: To calculate the mL to administer, divide the ordered dose (3 mg) by the concentration (4 mg/mL). 3 mg ÷ 4 mg/mL = 0.75 mL. Rounding to the nearest tenth, the correct dose to administer is 0.8 mL.

Similar Questions

While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?
The healthcare provider is caring for a client diagnosed with type 2 diabetes mellitus. Which intervention should the healthcare provider implement to assess the client’s glycemic control?
The nurse is completing a client's preoperative routine and finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next?
While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement?
During the insertion of a nasogastric tube (NGT), the client begins to cough and gag. What action should the healthcare professional take?

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