Question

Which is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)?

Answer 1

Correct Answers:

Achieve satisfactory pain control.

Rationale :

🔷 Pain management is the cornerstone of care for clients with degenerative joint disease (DJD) as the disease leads to chronic joint discomfort and mobility limitations.

🔷 Reducing pain improves the client’s functional ability, independence, and overall quality of life.

🔷 While rest and stress management are helpful, they are secondary to the goal of effective pain control in DJD management.

🔷 The care plan should prioritize interventions such as analgesic administration, heat/cold therapy, and joint protection techniques.

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Answer 2

Correct Answers:

Ask the client to describe the pain.

Rationale :

🟢 Asking the client to describe the pain helps the nurse assess the quality, character, and associated symptoms such as burning, stabbing, or aching sensations.

🟢 This information is vital for creating a personalized pain management plan and evaluating the effectiveness of interventions.

🟢 Objective tools like numeric scales measure intensity, but subjective description reveals pain quality.

🟢 This is especially critical in osteoarthritis, where pain may vary in pattern and impact on mobility.

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Answer 3

Correct Answers:

Discuss ethical concerns about placebo use with the healthcare provider.

Rationale :

♦ Placebo use without informed consent is ethically unacceptable in standard clinical care.

♦ Nurses must advocate for clients by addressing ethical implications with the prescribing provider.

♦ Discussing the concerns helps uphold client autonomy, trust, and professional integrity.

♦ It is essential to ensure clients receive genuine, evidence-based pain management.

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Answer 4

Correct Answers:

Obtain a clean, voided urine specimen for analysis.

Rationale :

🔶New onset urinary incontinence in older adults may result from underlying infections or other treatable causes.

🔶A urine analysis is the first step in identifying conditions such as urinary tract infections (UTIs).

🔶Initiating diagnostics before interventions ensures targeted and effective care.

🔶It avoids masking symptoms or delaying treatment of reversible causes.

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Answer 5

Correct Answers:

Position bedside table for client to lean across.

Rationale :

💠Clients with pancreatitis often experience pain relief by leaning forward, which reduces tension on inflamed tissues.

💠This posture can improve comfort more effectively than lying flat.

💠The bedside table offers physical support and helps maintain the preferred position.

💠Respecting the client's instinctive posture enhances non-pharmacologic pain control.

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Answer 6

Correct Answers:

Apply the client's positive airway pressure device.

Rationale :

🔶Clients with obstructive sleep apnea (OSA) are at significant risk of respiratory depression when receiving opioid analgesics due to compromised airway patency during sleep.

🔶Applying the positive airway pressure (PAP) device helps maintain a patent airway by delivering constant airflow, thus preventing airway collapse.

🔶The immediate use of this device is crucial after administering an opioid because it mitigates the risk of hypoventilation, apnea episodes, and hypoxia.

🔶Ensuring respiratory support with PAP before leaving the client is a critical safety measure that aligns with evidence-based care for patients with OSA receiving sedation or analgesia.

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Answer 7

Correct Answers:

Question the client about the frequency of falls in recent months.

Rationale :

💠 In functional assessments, especially for older adults transitioning to rehabilitation, a fall history provides crucial data on mobility and safety.

💠 Frequent falls may indicate balance issues, muscle weakness, or medication-related side effects, all of which influence the rehabilitation care plan.

💠 This information allows the nurse to identify the need for assistive devices, physical therapy, or home modifications.

💠 It also supports fall prevention strategies that reduce the risk of further injury and hospital readmissions.

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Answer 8

Correct Answers:

Question the client about the frequency of falls in recent months.

Rationale :

🟡 Fall frequency is a standard component of geriatric functional evaluations, especially when assessing recovery potential after hospitalization.

🟡 Clients with recent falls are more likely to have gait instability, cognitive impairment, or orthostatic hypotension, which need to be managed.

🟡 Understanding fall history helps the team tailor a personalized rehabilitation strategy.

🟡 This intervention is proactive and reflects fall risk screening per clinical guidelines for older adults.

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Answer 9

Correct Answers:

Urinary output of 30 to 60 mL/hr.

Rationale :

🔴 Before administering IV potassium chloride, it is essential to ensure renal function is intact by confirming adequate urine output.

🔴 If the kidneys are unable to excrete potassium, it can accumulate in the blood and lead to dangerous hyperkalemia, risking cardiac arrhythmias.

🔴 A urine output of at least 30 mL/hr confirms that the kidneys can filter and excrete potassium effectively.

🔴 This is a safety checkpoint that must be verified before any potassium-containing IV fluids are started.

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Answer 10

Correct Answers:

Pull the pinnae up and back to administer the drops.

Rationale :

🟣 For adult ear drop administration, pulling the pinna up and back straightens the external auditory canal, allowing proper delivery of medication to the tympanic membrane.

🟣 This method maximizes medication effectiveness by ensuring deeper penetration into the ear canal.

🟣 Educating the client or caregiver on this technique promotes correct self-administration and reduces the risk of medication errors.

🟣 Incorrect technique can cause residual fluid, discomfort, or ineffective treatment for infections.

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RN HESI Exit~2023 Exam 1

No.

1 :
Which is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)?

2 :
The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking because of increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?

3 :
The health care provider prescribes a placebo instead of pain medication. Which intervention should the nurse implement?

4 :
An older adult client arrives at the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement?

5 :
A client diagnosed with pancreatitis is reporting severe epigastric pain and intense nausea.After the nurse administers a narcotic analgesic and an antiemetic, the client insists on sitting up and leaning forward. Which action should the nurse implement?

6 :
The nurse places an opioid patch on the chest of a client with intractable pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?

7 :
An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

8 :
An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

9 :
A client with type 1 diabetes mellitus (DM) is admitted in diabetic ketoacidosis. Treatment is initiated, and the nurse is preparing to administer IV fluids containing potassium chloride. Which assessment data is most important for the nurse to obtain before starting the infusion?

10 :
The healthcare provider prescribes ear drops to an adult client with an ear infection. Which teaching should the nurse provide?

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RN HESI Exit~2023 Exam 1

No.

1 : Which is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)?

2 : The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking because of increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?

3 : The health care provider prescribes a placebo instead of pain medication. Which intervention should the nurse implement?

4 : An older adult client arrives at the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement?

5 : A client diagnosed with pancreatitis is reporting severe epigastric pain and intense nausea.After the nurse administers a narcotic analgesic and an antiemetic, the client insists on sitting up and leaning forward. Which action should the nurse implement?

6 : The nurse places an opioid patch on the chest of a client with intractable pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?

7 : An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

8 : An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

9 : A client with type 1 diabetes mellitus (DM) is admitted in diabetic ketoacidosis. Treatment is initiated, and the nurse is preparing to administer IV fluids containing potassium chloride. Which assessment data is most important for the nurse to obtain before starting the infusion?

10 : The healthcare provider prescribes ear drops to an adult client with an ear infection. Which teaching should the nurse provide?

1 :
Which is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)?

2 :
The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking because of increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?

3 :
The health care provider prescribes a placebo instead of pain medication. Which intervention should the nurse implement?

4 :
An older adult client arrives at the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement?

5 :
A client diagnosed with pancreatitis is reporting severe epigastric pain and intense nausea.After the nurse administers a narcotic analgesic and an antiemetic, the client insists on sitting up and leaning forward. Which action should the nurse implement?

6 :
The nurse places an opioid patch on the chest of a client with intractable pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?

7 :
An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

8 :
An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

9 :
A client with type 1 diabetes mellitus (DM) is admitted in diabetic ketoacidosis. Treatment is initiated, and the nurse is preparing to administer IV fluids containing potassium chloride. Which assessment data is most important for the nurse to obtain before starting the infusion?

10 :
The healthcare provider prescribes ear drops to an adult client with an ear infection. Which teaching should the nurse provide?