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 injecti
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Nursing Elites

HESI RN

HESI Fundamentals Quizlet

1. 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?

Correct answer: C

Rationale: Choice C is the correct answer because focusing on the client's demonstrated ability to self-administer the injection is likely to reinforce his level of competence without sounding punitive. By acknowledging the client's correct performance during the self-injection, the nurse can boost the client's confidence, encouraging him to assume total responsibility for the daily injections. Choices A, B, and D do not directly highlight the client's competence in self-administration, which may not be as effective in promoting independent self-care.

2. The client is receiving discharge teaching for a new diagnosis of asthma. Which statement by the client indicates a need for further teaching?

Correct answer: B

Rationale: The statement 'I should avoid using my inhaler unless I am having an asthma attack' (B) indicates a need for further teaching. It is important for clients to use their inhaler as prescribed, which may include regular use to prevent asthma attacks. Choice A is correct because using the inhaler when feeling short of breath can help manage asthma symptoms. Choice C is also correct as using the inhaler before exercise can prevent exercise-induced symptoms. Choice D is correct as rinsing the mouth after using the inhaler helps prevent oral thrush, a potential side effect of inhaled corticosteroids. Therefore, option B is the most concerning statement that needs clarification.

3. 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?

Correct answer: A

Rationale: The wife is correctly performing the passive range-of-motion exercises by holding the arm above and below the elbow. The nurse should acknowledge this correct technique (A). It is essential to keep the joint uncovered (B) during exercises, while ensuring the rest of the body remains covered for warmth and privacy. Choices (C) and (D) do not provide optimal support to the joint for effective movement.

4. Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?

Correct answer: C

Rationale: The most crucial instruction for a client with limited mobility to prevent venous thrombosis is to perform dorsiflexion and plantarflexion of the feet 10 times each hour. These exercises help promote venous return, reducing the risk of thrombosis by preventing blood stasis in the lower extremities. While other measures like turning in bed and staying hydrated are beneficial, promoting venous return through foot exercises is the priority in preventing venous thrombosis in clients with limited mobility. Dorsiflexion and plantarflexion directly target the calf muscle pump, aiding in the circulation of blood back to the heart and preventing clot formation. The other options, such as cough and deep breathing exercises, turning in bed, and hydration, are important for overall health but do not directly address venous stasis and thrombosis prevention in the same way as foot exercises.

5. A client is receiving total parenteral nutrition (TPN). Which assessment finding is most concerning to the nurse?

Correct answer: D

Rationale: A temperature of 100.4°F (38°C) (D) is the most concerning finding for a client receiving total parenteral nutrition (TPN) as it may indicate an infection, which poses a significant risk. Monitoring blood glucose level (A), blood pressure (B), and serum albumin (C) are also important, but an elevated temperature suggests a potential serious complication that requires immediate attention.

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