Hesi Rn Fundamental NSG

Correct Answer:

Measure oxygen saturation.

Explanation:

Use of accessory muscles indicates labored breathing and potential respiratory distress. The priority is to determine how well the client is oxygenating. Pulse oximetry is a quick, noninvasive method to assess oxygen saturation and guides the need for further interventions like supplemental oxygen or escalation of care.

Why Other Options are Wrong:

Determine pulse pressure.

Pulse pressure (systolic minus diastolic BP) can give information about cardiovascular status but does not directly assess respiratory function or gas exchange.

Check for neck vein distention.

While this may reveal signs of fluid overload or cardiac issues, it does not immediately help assess oxygenation status, which is more urgent here.

Auscultate heart sounds.

Heart sounds give information about cardiac function but are not the priority when respiratory distress is suspected.

Correct Answer:

Opioid analgesic received one hour ago.

Explanation:

Opioids commonly cause sedation, dizziness, or impaired coordination, especially shortly after administration. These side effects significantly increase the risk of falls and must be addressed in the plan of care through fall precautions and close monitoring.

Why Other Options are Wrong:

Expressed feelings of depression.

Depression may affect activity levels but is not a direct or immediate risk factor for falls unless accompanied by psychomotor retardation or medication effects.

Recent serum hemoglobin level of 16 g/dL (160 g/L).

This is a normal hemoglobin level, indicating good oxygen-carrying capacity. It does not contribute to fall risk.

Stooped posture with a steady gait.

Posture alone does not necessarily indicate instability or fall risk, especially if the gait remains steady.

Correct Answer:

A. A weak urinary stream.

Explanation:

Suprapubic tenderness combined with a sensation of incomplete bladder emptying after urination is commonly associated with urinary retention or bladder outlet obstruction. In older adult males, this is often due to benign prostatic hyperplasia (BPH). BPH causes the prostate gland to enlarge, which can compress the urethra and lead to symptoms such as a weak urinary stream, hesitancy, dribbling, and incomplete emptying. A weak stream is a classic symptom of this condition, and it supports the suspicion of an obstructive urological issue when combined with suprapubic discomfort.

Why the other options are incorrect:

B. A cloudy discharge

This may suggest a urinary tract infection or possibly a sexually transmitted infection, but it is not the most directly associated finding with suprapubic pressure and urinary retention.

C. Black tarry stools

These indicate gastrointestinal bleeding, typically from the upper GI tract. This symptom is unrelated to urinary complaints and would not be expected based on the information provided.

D. An overactive bladder

Overactive bladder involves frequent urination, urgency, and sometimes incontinence. While urgency can lead to a sensation of pressure, it does not typically involve suprapubic tenderness or a feeling of incomplete emptying after urination.

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:

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. Nailbed pink.

Explanation:

The photo shows fingernails with a healthy pink color of the nailbeds, which is a sign of adequate blood circulation and oxygenation. Documenting the pink nailbed is accurate because it reflects the normal vascular status of the client’s extremities, confirming no signs of cyanosis or circulatory impairment.

Why the other options are incorrect:

A. Fingernail pitting present. This refers to small depressions in the nail plate typically seen in psoriasis or other skin disorders. The photo does not show this abnormality, so this documentation would be incorrect.

B. Capillary refill less than 3 seconds. This option would require the nurse to perform a capillary refill test by pressing on the nailbed and timing how quickly the color returns. This is not something that can be seen just by observation, and the image does not provide evidence of this test being done.

C. Nail care needed. This is a general note that would apply if the nails appeared dirty, overgrown, or otherwise in need of maintenance. The image shows well-kept nails, so this is not a necessary documentation at this time.

Correct Answer:

Call the healthcare provider (HCP) to have the procedure rescheduled.

Explanation:

The client has already received an opioid, which impairs decision-making capacity, making any new consent invalid. A surgical consent form with conflicting information (wrong limb listed vs. marked) is a serious safety issue. The procedure must be delayed until correct, legally sound consent can be obtained with the client fully alert and oriented.

Why Other Options are Wrong:

Have the client sign another form before surgery.

Since the client has already received a narcotic, they are not legally competent to sign a new consent form.

Call the nearest relative to come in and sign a new form.

Family members cannot legally consent unless the client is deemed incompetent and a legal guardian or power of attorney is appointed.

Cross out the error and initial the consent form.

Altering legal documents like consent forms by crossing out and initialing is not acceptable. Consent must be clear, correct, and signed under full capacity.

Correct Answer:

The importance of using vaginal lubricants.

Explanation:

In older adult women, decreased estrogen levels lead to vaginal dryness and thinning of the vaginal walls, increasing the risk of tearing during intercourse. Using a vaginal lubricant can help reduce friction and trauma, making this the most important and immediate teaching point to prevent future injury.

Why Other Options are Wrong:

Methods used to practice safe sex.

While always important, this content does not directly address the cause of the vaginal tear, which is most likely due to friction and dryness rather than infection.

Information about alternative ways to express sexuality.

This can be part of broader sexual health education but is not as directly helpful for preventing further vaginal injury as lubrication is.

Intercourse positions that can help prevent tears.

This may provide some relief, but lubrication is a more universal and immediately effective intervention to reduce tearing.

Correct Answer:

Confirm that bowel sounds are present.

Explanation:

Before initiating enteral feedings, it is essential to confirm the presence of bowel sounds, as this indicates that the gastrointestinal (GI) tract is functioning and able to digest and absorb the nutrients. Initiating feeding without bowel activity can increase the risk of complications such as abdominal distention, nausea, vomiting, or even aspiration.

Why Other Options are Wrong:

Measure the client’s total body weight.

While useful for tracking nutritional progress, weight measurement does not determine readiness for feeding. It provides baseline data but is not a critical pre-feeding assessment.

Evaluate the client’s ability to swallow.

Swallowing ability is not necessary to assess before initiating a feeding via tube, since the food bypasses the oral route. This would be more relevant if the client were eating orally.

Observe for signs of fluid volume deficit.

Although hydration status is important, this has likely already been addressed upon admission. It is not the priority assessment immediately before feeding begins through a tube.