Question

A client tells the nurse about starting an aerobic workout program to lose weight and help with insomnia. The client states that it still takes over an hour to fall asleep at night. Which action should the nurse implement?

Answer 1

Correct Answers:

Ask the client to describe the exercise schedule that he has been following.

Rationale :

🔷 This allows the nurse to assess timing and intensity of exercise, which can impact sleep.

🔷 Exercise too close to bedtime can increase alertness, interfering with falling asleep.

🔷 Gathering details guides further recommendations for behavioral sleep interventions.

🔷 It establishes a baseline to evaluate appropriateness of current habits.

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Answer 2

Correct Answers:

Verify the prescribed dosage with healthcare provider.

Rationale :

🔶 The nurse must clarify unusual or potentially unsafe prescriptions with the prescriber.

🔶 This action follows the nursing responsibility to prevent medication errors.

🔶 Drug handbooks offer guidance, but prescriber clarification ensures patient safety.

🔶 Verifying high-dose orders prevents adverse reactions and maintains accountability.

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Answer 3

Correct Answers:

Use everyday language when explaining issues.

Rationale :

🟡 Older adults benefit from clear, simple communication to support understanding.

🟡 Avoiding jargon improves retention of instructions and enhances health literacy.

🟡 Everyday language reduces confusion and encourages patient participation.

🟡 Clear explanations also facilitate independent decision-making.

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Answer 4

Correct Answers:

Ask the client what is causing the grimacing.

Rationale :

🟣 This acknowledges the nonverbal sign of pain while respecting the client’s denial.

🟣 Open-ended questioning encourages expression of discomfort in a non-threatening way.

🟣 Pain perception is subjective—engagement supports a more accurate assessment.

🟣 Addressing discomfort early can lead to timely intervention and comfort.

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Answer 5

Correct Answers:

Obtain a new catheter.

Rationale :

🔵 Once a catheter tip has emerged from the urethra, it is no longer sterile.

🔵 Reinserting it can introduce infection into the urinary tract.

🔵 A new catheter ensures adherence to aseptic technique.

🔵 This action is a standard part of infection control protocols

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Answer 6

Correct Answers:

When the client voided following catheter removal.

Rationale :

⚪ First post-catheter void is critical to detect urinary retention or retention symptoms.

⚪ Delayed voiding can lead to bladder distention or infection.

⚪ Documenting time helps monitor urinary function recovery.

⚪ Prompt intervention can prevent complications like overflow incontinence.

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Answer 7

Correct Answers:

Risk for impaired skin integrity.

Rationale :

🟢 Neuropathy leads to loss of sensation, making foot injuries hard to detect.

🟢 This increases risk of ulcers and infections, especially in the feet.

🟢 Monitoring and skin care education is key to prevention of breakdown.

🟢 The nurse’s focus should be skin protection and regular inspection.

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Answer 8

Correct Answers:

Bears body weight on the palms of hands during the crutch gait.

Rationale :

🟠 Proper crutch use involves weight-bearing on hands, not axillae, to avoid nerve damage.

🟠 Supporting weight through palms prevents brachial plexus compression.

🟠 This method ensures safe and effective mobility support.

🟠 Education in correct hand placement prevents long-term complications

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Answer 9

Correct Answers:

Avoid drinking caffeinated beverages late in the day.
Establish a regular time for going to bed and getting up.

Rationale :

🟣 B. Avoid drinking caffeinated beverages late in the day

Caffeine is a stimulant that can worsen sleep disturbances in older adults.

Avoiding it supports natural circadian rhythm.

It promotes more restful sleep patterns.

🟣 C. Establish a regular time for going to bed and getting up

Routine supports the body’s biological sleep-wake cycle.

This helps regulate sleep timing and quality.

It is a first-line behavioral approach to insomnia management.

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Answer 10

Correct Answers:

Change coccyx dressing, perform tracheostomy care, restart the IV line.

Rationale :

🟤 Dressing changes for MRSA should be done first to prevent contamination of other supplies. 🟤 Tracheostomy care is invasive and should follow once dressing is complete. 🟤 Restarting the IV line last prevents introducing pathogens to a vascular site. 🟤 This order follows infection control priorities and reduces cross-contamination risk.

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WGU-Hesi-RN Fundamentals of Nursing Exam 2

No.

1 :
A client tells the nurse about starting an aerobic workout program to lose weight and help with insomnia. The client states that it still takes over an hour to fall asleep at night. Which action should the nurse implement?

3 :
When providing health teaching to older adult clients, which action is most important for the nurse to implement?

4 :
The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

5 :
The nurse is inserting a urinary catheter that has been prescribed for the client. When the tip of the catheter reemerges from the insertion site, which action should the nurse take next

6 :
When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain

7 :
The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

8 :
The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?

9 :
An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. Which action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

10 :
A client is in contact isolation due to a stage IV coccyx wound infected with methicillin resistant Staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client's room. In which order should the nurse perform the interventions?

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WGU-Hesi-RN Fundamentals of Nursing Exam 2

No.

1 : A client tells the nurse about starting an aerobic workout program to lose weight and help with insomnia. The client states that it still takes over an hour to fall asleep at night. Which action should the nurse implement?

3 : When providing health teaching to older adult clients, which action is most important for the nurse to implement?

4 : The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

5 : The nurse is inserting a urinary catheter that has been prescribed for the client. When the tip of the catheter reemerges from the insertion site, which action should the nurse take next

6 : When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain

7 : The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

8 : The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?

9 : An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. Which action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

10 : A client is in contact isolation due to a stage IV coccyx wound infected with methicillin resistant Staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client's room. In which order should the nurse perform the interventions?

1 :
A client tells the nurse about starting an aerobic workout program to lose weight and help with insomnia. The client states that it still takes over an hour to fall asleep at night. Which action should the nurse implement?

3 :
When providing health teaching to older adult clients, which action is most important for the nurse to implement?

4 :
The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

5 :
The nurse is inserting a urinary catheter that has been prescribed for the client. When the tip of the catheter reemerges from the insertion site, which action should the nurse take next

6 :
When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain

7 :
The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

8 :
The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?

9 :
An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. Which action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

10 :
A client is in contact isolation due to a stage IV coccyx wound infected with methicillin resistant Staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client's room. In which order should the nurse perform the interventions?