a client is admitted to the hospital with intractable pain what instruction should the nurse provide the unlicensed assistive personnel uap who is pre
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Nursing Elites

HESI RN

HESI Quizlet Fundamentals

1. A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath?

Correct answer: A

Rationale: The correct instruction for the unlicensed assistive personnel (UAP) preparing to assist a client with intractable pain is to take measures to promote as much comfort as possible. Intractable pain is resistant to relief, so ensuring comfort during all activities, including a bed bath, is crucial to enhance the client's well-being and quality of care.

2. The client is 5 feet from the bathroom door when he states, 'I feel faint.' Before the nurse can get the client to a chair, the client starts to fall. What is the priority action for the nurse to take?

Correct answer: D

Rationale: The priority action for the nurse in this situation is to gently lower the client to the floor. This action helps prevent injury to both the client and the nurse. It is important to ensure a safe environment and protect the client from falling, as well as to maintain the nurse's own safety while providing care.

3. While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement?

Correct answer: A

Rationale: The client is exhibiting symptoms of normal grief, such as flat affect, withdrawal, and sleep disturbances, following the recent death of his life partner. It is crucial for the nurse to encourage the client to see the clinic's grief counselor. Grief counseling can provide the client with appropriate support and coping strategies during this grieving process, helping him navigate through his loss and emotions effectively.

4. UAP has lowered the head of the bed to change the linens for a client who is bedbound with a foley catheter and enteral tube feeds. Which change from the client warrants the most immediate intervention by the nurse?

Correct answer: D

Rationale: Purulent drainage indicates infection at the insertion site, which requires immediate attention to prevent complications.

5. The health care provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication?

Correct answer: B

Rationale: When a medication is administered via the IV route, the absorptive process is bypassed, leading to a more rapid onset of action. This results in a faster effect of the drug. Choice A is incorrect because changing the route of administration does not necessarily lead to increased tolerance or the need for a higher dose. Choice C is incorrect as changing the route of administration does not directly affect the protein binding of a medication. Choice D is incorrect because increasing the therapeutic index would actually reduce the risk of toxicity, not increase it.

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