when evaluating the effectiveness of a clients nursing care the nurse first reviews the expected outcomes identified in the plan of care what action s
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Nursing Elites

HESI RN

HESI Fundamentals Practice Test

1. When evaluating the effectiveness of a client’s nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

Correct answer: A

Rationale: After reviewing the expected outcomes identified in the plan of care, the nurse's next step should be to determine if these outcomes were realistic. This assessment helps in understanding if the goals set were achievable and appropriate for the client's condition before proceeding to compare them with current client data or modifying nursing interventions. By verifying the realism of the expected outcomes, the nurse ensures a solid foundation for further evaluation and adjustment of the care plan. Option B is incorrect because obtaining current client data comes after assessing the realism of the expected outcomes. Option C is incorrect because modifying nursing interventions should be based on the assessment of the expected outcomes' realism. Option D is incorrect as reviewing professional standards of care is important but not the immediate next step after assessing the expected outcomes' realism.

2. A client with a history of heart failure is admitted with a diagnosis of pulmonary edema. Which intervention should the nurse implement first?

Correct answer: A

Rationale: Administering oxygen via a non-rebreather mask is the priority intervention for a client with pulmonary edema to improve oxygenation and address respiratory distress. Adequate oxygenation is essential to support vital organ function. Administering furosemide intravenously, inserting a Foley catheter to monitor urine output, and positioning the client in a high Fowler's position are important interventions but are secondary to ensuring optimal oxygenation in this client with pulmonary edema.

3. A client has a nursing diagnosis of 'spiritual distress.' What intervention is best for the nurse to implement when caring for this client?

Correct answer: D

Rationale: When a client is going through spiritual distress, employing reflective listening techniques is crucial. This method allows the client to voice their concerns and emotions, providing them with a supportive environment to explore their feelings. Options A and B do not directly address the client's spiritual distress and may undermine the client's feelings. While option C involves a chaplain, using reflective listening directly involves the nurse in addressing and supporting the client's spiritual concerns.

4. The UAP is positioning a newly admitted client with a seizure disorder in a supine position. The UAP is placing soft pillows along the side rails. What action should the nurse take?

Correct answer: A

Rationale: To prevent the risk of suffocation, soft blankets are preferred over pillows for padding side rails in clients with seizure disorders. Pillows can pose a suffocation hazard, especially during a seizure episode when the client's movements may be uncontrolled. Instructing the UAP to use soft blankets instead of pillows is crucial for ensuring the client's safety. Choice B is incorrect because pillows can be hazardous during a seizure. Choice C is incorrect as side-lying position may not be appropriate for a client with a seizure disorder. Choice D is incorrect as it does not address the safety concern related to using pillows.

5. A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago but feels fine now. What action is best for the nurse to take?

Correct answer: C

Rationale: Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small-bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes. The nurse should assess tube placement in this way before taking any other action to ensure the tube is still in the correct position and prevent potential complications. Choice A is incorrect because further assessment is needed due to the risk of tube displacement. Choice B is incorrect as stopping the feeding and involving the family is premature without confirming tube placement. Choice D is incorrect as injecting air and auscultating for gurgling is not the recommended method to confirm tube placement.

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