Question

The client is an 81-year-old male was admitted for pneumonia 3 days ago

Answer 1

Correct Answers

Blank 1 Correct Option: Stage 2 pressure injury
Blank 2 Correct Option: Place a hydrocolloid dressing over the area and Request a prescription for antibiotic ointment from the physician
Blank 3 Correct Option: Nutritional intake and Skin integrity

Rationale :

💠 The 2 cm × 4 cm partial-thickness abrasion indicates a Stage 2 pressure injury, involving damage to the epidermis and dermis but no slough or deep tissue involvement.

💠 A hydrocolloid dressing is appropriate to maintain a moist environment, enhance healing, and protect from further pressure or friction from CPAP straps.

💠 Since the area is open and susceptible to infection, topical antibiotic ointment is a preventive measure, especially for elderly clients at higher risk.

💠 Monitoring skin integrity is essential to evaluate healing progress or signs of infection or deterioration.

💠 Adequate nutritional intake, especially protein, zinc, and vitamin C, supports cellular regeneration and wound healing in older adults.

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Answer 2

Correct Answers:

Good Samaritan immunity.

Rationale :

💠 The nurse rendered emergency assistance at the scene, which is protected under Good Samaritan laws if no gross negligence occurred.

💠 These laws are designed to encourage bystanders, especially healthcare professionals, to help in emergencies without fear of legal retaliation.

💠 The nurse reported the situation to EMS and did not abandon the victim, which further supports immunity.

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Answer 3

Correct Answers:

1.035.

Rationale :

💠 A urine specific gravity of 1.035 indicates concentrated urine, commonly due to dehydration.

💠 This client has a 3-day history of vomiting and diarrhea, leading to fluid volume deficit.

💠 The kidneys compensate by retaining water, resulting in high urine concentration.

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Answer 4

Correct Answers:

Reporting a change in a client's condition to the healthcare provider.

Rationale :

💠 SBAR is used for concise, structured communication about a patient’s clinical status to another provider.

💠 It ensures all critical elements (situation, background, assessment, recommendation) are clearly relayed.

💠 SBAR is ideal when reporting clinical changes that may require provider action.

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Answer 5

Correct Answers:

Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client.

Rationale :

💠 Clients with bacterial meningitis require droplet precautions, which include wearing a standard surgical mask, not a particulate respirator.

💠 A particulate filter mask (e.g., N95) is only necessary for airborne precautions, such as tuberculosis or varicella.

💠 The UAP does not need reassignment, and care can be safely provided with appropriate droplet PPE, ensuring continuity of client care.

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Answer 6

Correct Answers:

A well approximated incision site.

Rationale :

💠 A well approximated incision site means the wound edges are aligned without gaps, indicating primary intention healing.

💠 At one week post-op, absence of redness, swelling, or drainage is a sign of normal wound recovery.

💠 The presence of granulation tissue, eschar, or slough would indicate either secondary intention healing or infection, which are not expected in this scenario.

💠 Identifying expected wound healing patterns allows for early detection of complications like dehiscence or infection.

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Answer 7

Correct Answers:

Perform oropharyngeal suctioning.

Rationale :

💠 In a client who is vomiting and appears to be choking, the priority is to ensure a patent airway.

💠 Oropharyngeal suctioning removes secretions or gastric contents from the upper airway, reducing risk of aspiration.

💠 Since the client has an NG tube and is receiving enteral feeding, vomiting increases the risk of aspiration pneumonia.

💠 Suctioning is an immediate and critical action aligned with the ABC (Airway, Breathing, Circulation) priority framework.

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Answer 8

Correct Answers:

Assist to a bedside commode 30 minutes after meals.

Rationale :

💠 The gastrocolic reflex, triggered after meals, naturally stimulates peristalsis. 💠 Using this physiological response by providing the commode 30 minutes post-meal promotes timely bowel elimination.

💠 This reduces episodes of incontinence and helps retrain the bowel, improving control over time.

💠 Establishing a regular routine supports client dignity and psychological comfort.

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Answer 9

Correct Answers:

Positive external places.

Rationale :

💠 Guided imagery is a cognitive-behavioral technique that uses relaxing mental images to divert attention from pain.

💠 Focusing on serene, external environments like beaches or forests helps the client detach from physical discomfort.

💠 This technique enhances the production of endorphins, the body's natural pain relievers.

💠 It is an evidence-based intervention used in chronic pain management protocols.

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Answer 10

Correct Answers:

Compare the medication label to the order
Use at least 2 client identifiers before administering a dose
Document all medication in the electronic record as soon as it is given
Involve and educate clients in medication administration

Rationale :

🔹 A. Compare the medication label to the order — Ensures that the nurse gives the right medication and avoids drug errors.

🔹 B. Use at least 2 client identifiers — Prevents administering medication to the wrong patient, a major safety concern.

🔹 C. Document all medication in the electronic record as soon as it is given — Prevents duplicate administration, which occurred in this case.

🔹 D. Involve and educate clients in medication administration — Empowers patients to be active in care and to alert staff to potential errors.

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Hesi-RN Fundamentals of Nursing

No.

1 :
The client is an 81-year-old male was admitted for pneumonia 3 days ago

Correct Answers

3 :
The nurse is assessing a client who reports a 3 day history of vomiting and diarrhea and experiencing difficulty in tolerating oral fluids. Which urine specific gravity value would the nurse expect to see on initial testing?Reference Range:Urine Specific Gravity [1.005 to 1.03]

4 :
The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?

6 :
The nurse is caring for a client one-week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

7 :
A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

8 :
A client with chronic fecal incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?

9 :
The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?

10 :
The client is a 64-year-old female began to have difficulty breathing

Answer Options

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Hesi-RN Fundamentals of Nursing

No.

1 : The client is an 81-year-old male was admitted for pneumonia 3 days ago

Correct Answers

3 : The nurse is assessing a client who reports a 3 day history of vomiting and diarrhea and experiencing difficulty in tolerating oral fluids. Which urine specific gravity value would the nurse expect to see on initial testing?Reference Range:Urine Specific Gravity [1.005 to 1.03]

4 : The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?

6 : The nurse is caring for a client one-week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

7 : A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

8 : A client with chronic fecal incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?

9 : The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?

10 : The client is a 64-year-old female began to have difficulty breathing

Answer Options

1 :
The client is an 81-year-old male was admitted for pneumonia 3 days ago

3 :
The nurse is assessing a client who reports a 3 day history of vomiting and diarrhea and experiencing difficulty in tolerating oral fluids. Which urine specific gravity value would the nurse expect to see on initial testing?Reference Range:Urine Specific Gravity [1.005 to 1.03]

4 :
The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?

6 :
The nurse is caring for a client one-week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

7 :
A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

8 :
A client with chronic fecal incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?

9 :
The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?

10 :
The client is a 64-year-old female began to have difficulty breathing