a female clients significant other has been at her bedside providing reassurances and support for the past 3 days as desired by the client the clients
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Nursing Elites

HESI RN

HESI Fundamentals Quizlet

1. A female client’s significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client’s estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?

Correct answer: B

Rationale: In a situation where a client's estranged husband demands to restrict the visitation of the significant other, it is essential to prioritize the client's wishes while addressing the conflict. Requesting a consultation with the ethics committee is appropriate as it allows for a comprehensive and impartial resolution, ensuring the client's autonomy and well-being are upheld. Option A is incorrect because visitation privileges are not solely determined by a healthcare provider's prescription in this scenario. Option C may not be appropriate as it puts the client in a potentially uncomfortable or unsafe position. Option D, while important, does not directly address the conflict between the estranged husband and the significant other.

2. A healthcare professional stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later, the client has to have the leg amputated and sues the healthcare professional for malpractice. What is the most likely outcome of this lawsuit?

Correct answer: C

Rationale: The Good Samaritan Act protects healthcare professionals who provide care in good faith and offer reasonable assistance in emergencies. This law shields them from malpractice claims, even if the outcome for the client is unfavorable. In this scenario, the healthcare professional is likely to be protected from judgment under the Good Samaritan Act. Choice A is incorrect because the situation does not involve the Patient's Bill of Rights, but rather the Good Samaritan Act. Choice B is incorrect as the license revocation is not a typical outcome in Good Samaritan cases. Choice D is incorrect as the Good Samaritan Act provides immunity from liability in such emergency situations.

3. A client with a history of coronary artery disease (CAD) is admitted with chest pain. Which intervention should the nurse implement first?

Correct answer: C

Rationale: In a client with a history of coronary artery disease (CAD) experiencing chest pain, the priority intervention for the nurse to implement first is to apply oxygen via nasal cannula. Oxygenation is crucial to ensure adequate oxygen supply to the tissues and the heart. This intervention takes precedence over administering sublingual nitroglycerin, obtaining an ECG, or initiating continuous cardiac monitoring. While these interventions are important, ensuring adequate oxygenation is the initial priority in the management of a client with chest pain.

4. A client is 2 days post-op from thoracic surgery and is complaining of incisional pain. The client last received pain medication 2 hours ago. He is rating his pain as a 5 on a 1-10 scale. After calling the provider, what is the nurse's next action?

Correct answer: A

Rationale: In this scenario, since no additional pain medication is available, the nurse should recommend non-pharmacological pain management techniques. Guided imagery and slow rhythmic breathing can help the client manage incisional pain effectively. These techniques can provide distraction and relaxation, potentially reducing the perception of pain without the need for additional medication.

5. While suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?

Correct answer: B

Rationale: When a client coughs during tracheostomy tube suctioning, the nurse should gently withdraw the suction tubing. This action allows the client to cough out mucus naturally, reducing the risk of further irritation and promoting effective airway clearance. Choice A is incorrect because suctioning deeper can cause trauma and increase the risk of complications. Choice C is incorrect as removing the suction quickly may not allow the client to clear the mucus adequately. Choice D is incorrect as inserting and removing the suction multiple times can lead to unnecessary trauma and discomfort for the client.

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