earlier this morning an elderly hispanic female was discharged to a ltc facility the family members are now gathered in the hallway outside her room w
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Nursing Elites

HESI RN

HESI Fundamentals

1. Earlier this morning, an elderly Hispanic female was discharged to a LTC facility. The family members are now gathered in the hallway outside her room. What is the best action?

Correct answer: B

Rationale: In this situation, providing space and privacy for the family allows them to openly discuss their concerns regarding the client’s discharge. It respects the family's need for support, communication, and involvement in the decision-making process, ultimately fostering a more effective and compassionate care environment.

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. During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report?

Correct answer: D

Rationale: In response to the mother's report, the nurse should assess the family's home environment first to identify any factors that may hinder the establishment of bedtime routines conducive to sleep. Factors such as noise, light, distractions, or other environmental aspects could be contributing to the child's difficulty falling asleep at a reasonable hour and waking up in the morning.

4. The healthcare provider is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition?

Correct answer: A

Rationale: A low serum albumin level is the most reliable indicator of chronic protein malnutrition. Serum albumin levels reflect long-term protein status, and a significantly lowered level usually indicates ongoing protein deficiency. Other laboratory values, such as serum transferrin, hemoglobin, or cholesterol levels, may be affected by various factors and conditions, but serum albumin is a more specific marker for chronic protein malnutrition.

5. When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum 'tents' when gently pinched. Which action should the nurse implement?

Correct answer: C

Rationale: When the nurse observes that the client's skin over the sternum 'tents' when gently pinched, it is a classic sign of fluid volume deficit. This finding indicates dehydration and the need to restore the client's fluid volume. Therefore, the appropriate action for the nurse is to continue the planned nursing interventions aimed at addressing the fluid deficit. Choice A is incorrect as jugular vein distention is associated with fluid overload, not deficit. Choice B is incorrect as offering high-protein snacks does not directly address the fluid volume deficit. Choice D is incorrect as the priority is to address the fluid deficit before addressing skin integrity issues.

Similar Questions

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