Hesi Rn Fundamental NSG

Correct Answer:

Use a moist towel as a skin barrier.

Explanation:

To prevent burns and skin damage, a barrier such as a moist towel should always be placed between the heat source and the client’s skin. This is a standard nursing intervention during heat therapy to protect tissue integrity.

Why Other Options are Wrong:

Obtain a prescription for heat application.

While some facilities may require provider orders, in many cases, nurses can implement non-invasive comfort measures like heat therapy under standard protocols. This is not the most immediate or practical action in this scenario.

Assess skin every 30 minutes after application.

Assessment is important, but waiting 30 minutes could be too long to detect early signs of burns or redness. Initial focus should be on prevention through proper application technique, such as using a barrier.

Demonstrate use of temperature control.

This is helpful if the client is self-administering therapy at home, but it does not address the immediate safety concern—preventing burns during nurse-administered therapy.

Correct Answer:

D Maintain eye contact with the client when questions are asked.

Explanation:

When using an interpreter during a health interview, it is important to focus on the client and maintain eye contact with them. This demonstrates respect and ensures that the nurse is engaging with the client rather than the interpreter. The nurse should be attentive to the client's body language and responses, even if the communication is being facilitated by the interpreter.

Why the Other Options are Incorrect:

A Giving the interpreter a form that lists the interview questions: While it may seem helpful, this approach could limit the natural flow of conversation and does not allow for the flexibility needed in a health interview. It is better to speak directly and clearly to the client through the interpreter.

B Using an interpreter throughout the client's hospitalization: While consistent use of an interpreter is crucial, it is not necessary for the nurse to rely solely on the interpreter throughout the entire hospitalization. A single interview or interaction may not require a long-term arrangement.

C Asking the interpreter to tell the client to write down questions: This is not a practical solution in most healthcare settings. It could create confusion or further communication barriers, especially in a clinical interview that requires verbal responses.

Correct Answer:

A. Urine dipstick test

Explanation:

Frequent, painful urination is a classic symptom of a urinary tract infection (UTI). Individuals with uncontrolled diabetes are at increased risk for UTIs due to high blood glucose levels, which can promote bacterial growth. A urine dipstick test is a quick, non-invasive screening tool used to detect leukocytes, nitrites, blood, and glucose in the urine—markers that can indicate infection or other abnormalities. This is the most appropriate initial test in this scenario to confirm or rule out a UTI.

Why the Other Options are Incorrect:

B. Nitazine pH strip is used to detect amniotic fluid in cases of suspected rupture of membranes in pregnancy, not for assessing urinary symptoms.

C. Rapid strep test screens for streptococcal pharyngitis, which is unrelated to urinary symptoms.

D. Fingerstick glucose is relevant for monitoring diabetes but does not address the acute urinary symptoms the client is currently experiencing.

Correct Answer:

Ask the client to describe the pain.

Explanation:

Assessing quality of pain involves descriptive terms like "burning," "stabbing," "throbbing," or "aching." The only way to gather this information is by asking the client directly to describe what the pain feels like, making this the most accurate method to assess pain quality.

Why Other Options are Wrong:

Provide a numeric pain scale.

This assesses intensity, not quality, of pain.

Observe body language and movement.

This is useful for clients unable to verbalize pain, but it provides indirect signs—not a description of pain quality.

Identify effective pain relief measures.

This helps guide treatment but does not assess or clarify what the pain actually feels like to the client.

Correct Answer:

C. Serum prealbumin

Explanation:

Serum prealbumin is a critical marker for assessing the nutritional status of a client, particularly in evaluating protein malnutrition and the client’s risk for developing complications related to inadequate nutrition. Prealbumin has a shorter half-life (approximately 2-3 days), which makes it an ideal indicator for recent changes in nutritional intake and protein stores. A decrease in serum prealbumin levels can suggest inadequate protein intake or poor nutritional status, which is important for identifying potential nutritional deficiencies.

Why the Other Options are Incorrect:

A. Serum calcium: While serum calcium levels can be affected by various health conditions, including malnutrition, it is not the most specific indicator of overall nutritional status. It is more commonly used to assess bone health, parathyroid function, and calcium metabolism, rather than being the primary indicator of nutritional health.

B. Hemoglobin: Hemoglobin is important for assessing anemia and oxygen-carrying capacity in the blood, but it is not a direct measure of nutritional status. Anemia can be caused by several factors, including iron, folate, or vitamin B12 deficiencies, but hemoglobin alone does not provide a comprehensive view of a client's overall nutritional condition.

D. Hematocrit: Hematocrit measures the proportion of blood volume that is occupied by red blood cells. Like hemoglobin, it can indicate the presence of anemia, but it does not provide specific information regarding protein or overall nutritional status. It is more of a general indicator of hydration status and blood volume rather than nutritional health.

Correct Answer:

B. Auscultate the client's breath sounds.

Explanation:

The client's symptoms—awakening at night with cold sweats, difficulty breathing, and a racing heart—are concerning for acute heart failure exacerbation or a possible acute pulmonary edema event. The most immediate and relevant assessment the nurse should make is to auscultate the client’s breath sounds. This will help identify signs of fluid overload in the lungs, such as crackles or rales, which are common in heart failure. Early identification of pulmonary congestion or edema allows for timely intervention to prevent further complications.

Why the Other Options are Incorrect:

A. Ask about any environmental allergies: While allergies can cause respiratory symptoms, the client's symptoms (difficulty breathing, cold sweats, and racing heart) are more indicative of an acute cardiovascular event. Asking about allergies is not the priority in this situation, as it does not address the most immediate concern.

C. Assess the elasticity of the client's skin: Skin elasticity is typically assessed to gauge hydration status or possible malnutrition, but it does not directly relate to the cardiovascular issues the client is presenting with. The priority assessment in this case is to determine if there is a cardiovascular cause for the client's symptoms.

D. Measure the client's core temperature: A temperature assessment is important if there is suspicion of infection or fever, but the symptoms described (cold sweat, difficulty breathing, and racing heartbeat) are more consistent with heart failure exacerbation, making auscultation of breath sounds more critical in this situation.

Correct Answer:

Do not allow other activity to interrupt medication administration

Use at least 2 client identifiers before administering a dose

Question unusually large or small doses

Double check all dosage calculations

Explanation:

This situation illustrates how distractions and failure to confirm essential information can lead to serious medication errors. The nurse was interrupted and returned to the wrong room, administering a different dose. Using two identifiers, avoiding interruptions, questioning abnormal dosages, and verifying calculations would have prevented the error.

Why Other Options are Wrong:

Document all medication as soon as it is given.

This is good practice for recordkeeping but wouldn’t have prevented the mistake from happening. It’s reactive, not preventive.

Involve and educate clients in medication administration.

Although client awareness is beneficial, it cannot be relied on to prevent such errors—especially if the patient is unwell or unfamiliar with their medication specifics.

Correct Answer:

C. Acute pain, change in visual acuity, and foreign body sensation.

Explanation:

A subconjunctival hemorrhage is usually a benign condition that presents as a bright red patch on the sclera due to a small blood vessel break. Most cases are painless and resolve on their own without the need for medical intervention. However, the presence of acute pain, a noticeable decrease in visual acuity, and the sensation of a foreign body in the eye are warning signs that may indicate a more serious underlying ocular injury or condition. These symptoms suggest the possibility of deeper ocular involvement, such as a corneal abrasion, anterior uveitis, or increased intraocular pressure, all of which require prompt ophthalmologic evaluation.

Why the Other Options are Incorrect:

A. Diminished ability to focus on close work and needing more light is common with aging and presbyopia, not an urgent concern related to subconjunctival hemorrhage.

B. Burning, irritation, and tearing may indicate dry eyes or mild irritation, which are not usually urgent and can be managed conservatively.

D. Itchy, red, watery eyes are characteristic of allergic conjunctivitis, a non-emergent condition not typically associated with subconjunctival hemorrhage.

Correct Answer:

Remove the basin of water from the client’s bed immediately.

Explanation:

Soaking a client's foot in water while on the bed creates a safety hazard, including risk of spills, electrical injury, or skin breakdown due to prolonged moisture exposure. Since the client is confused and lethargic, they are at greater risk for injury. The nurse must act immediately to eliminate the risk.

Why Other Options are Wrong:

Remind the UAP to dry between the client’s toes completely.

Drying is important to prevent fungal infections, but the current setup poses an immediate safety hazard that must be addressed first.

Advise the UAP that this procedure is damaging to the skin.

This feedback is educational but not urgent. Immediate removal of the hazard is the priority.

Add skin cream to the basin of water while the foot is soaking.

This is inappropriate and may further damage the skin or cause slipperiness and injury risk.