the nurse assesses a 2 year old who is admitted for dehydration and finds that the peripheral iv rate by gravity has slowed even though the venous acc
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Nursing Elites

HESI RN

HESI Fundamentals Quizlet

1. The healthcare provider assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the healthcare provider do next?

Correct answer: B

Rationale: In this scenario, the appropriate next step for the healthcare provider is to check for kinks in the tubing and raise the IV pole. These issues can commonly cause a slowed IV rate. Applying a warm compress (Choice A) may not address the underlying problem of kinked tubing or incorrect IV pole height. Adjusting the tape that stabilizes the needle (Choice C) is important for securement but is not the priority in this situation. Flushing with normal saline and recounting the drop rate (Choice D) should only be done after ruling out mechanical issues like kinks in the tubing.

2. A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?

Correct answer: C

Rationale: The ANA's Scope and Standards of Nursing Practice are essential guidelines for nursing practice in various specialties, including mental health. The document outlines the expectations and responsibilities of nurses in providing high-quality care within their specific practice areas. In the context of opening a mental health services department, using the Scope and Standards specific to psychiatric–mental health nursing would ensure that the unit's nursing guidelines align with best practices and professional standards in mental health care. Choices A, B, and D are not focused on providing specific guidelines for nursing practice in a mental health services department, making them incorrect options.

3. A client is admitted with a diagnosis of left-sided heart failure. Which assessment finding is most consistent with this diagnosis?

Correct answer: D

Rationale: Orthopnea (D) is most consistent with left-sided heart failure. It is characterized by difficulty breathing when lying flat and is relieved by sitting up or standing. Dependent edema (A), ascites (B), and nocturia (C) are more commonly associated with right-sided heart failure. Dependent edema refers to swelling due to fluid accumulation, ascites is the accumulation of fluid in the peritoneal cavity, and nocturia is the excessive need to urinate during the night, all of which are more indicative of right-sided heart failure.

4. The healthcare provider is preparing an older client for discharge. Which method is best for the provider to use when evaluating the client's ability to perform a dressing change at home?

Correct answer: D

Rationale: Direct observation of the client performing the skill is the most effective method to assess the client's ability to independently change the dressing. This allows the healthcare provider to evaluate the client's technique, understanding, and readiness to perform the task at home. Choices A, B, and C are not as reliable as directly observing the client performing the dressing change. Determining the client's feelings may not accurately reflect their ability, asking the client to write about the procedure may not demonstrate their practical skills, and having a family member evaluate might not provide an accurate assessment of the client's ability.

5. A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulation therapy. Which statement by the client indicates a need for further teaching?

Correct answer: D

Rationale: The statement 'I should continue taking my over-the-counter herbal supplements' (D) indicates a need for further teaching because some herbal supplements can interact with anticoagulants, increasing the risk of bleeding. It is crucial to inform healthcare providers about all medications, including herbal supplements, to prevent adverse interactions. The other statements reflect appropriate understanding of precautions related to DVT and anticoagulation therapy.

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