HESI RN FUNDAMENTALS EXIT EXAM NEWEST 2024 TEST BANK COMPLETE 92 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS ALREADY GRADED A+)| NEW EXAMS!!
When caring for an immobile client, what nursing diagnosis has the highest priority?
A. Risk for fluid volume deficit
B. Impaired gas exchange
C. Altered tissue perfusion
D. Risk for impaired skin integrity - Answer-B. Impaired gas exchange
The nurses assesses an immobile, elderly male client and determines that his blood pressure is 138/60, his temperature is 95.8 F, and his output is 100 ml of concentrated urine during the last hour. He has wet-sounding lungs, and increased respiratory secretions. Based on these assessment findings, what nursing action is most important for the nurse to implement?
A. Encourage additional fluid intake
B. Turn the client q2h
C. Provide the client with an additional blanket
D. Administer a PRN anti-hypertensive prescription - Answer-B. Turn the client q2h
The home health nurse visits an elderly female client who had a brain attack three months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care?
A. The client's pulse rate is 10 beats higher than it was at the last visit one week ago
B. The nurse notes that there are numerous scatter rugs throughout the house
C. The husband, who is the caregiver, begins to weep when the nurse asks how he is doing
D. The client tells the nurse that she does not have much of an appetite today - Answer-B. The nurse notes that there are numerous scatter rugs throughout the house
The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch in diameter and finds that there is straw-colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record?
A. Stage 1 pressure sore draining sero-sanguineous drainage.
B. One-inch pressure sore draining serous fluid.
C. Pressure sore on heel with a small amount of purulent drainage.
D. Pressure sore at bony prominence with exudate noted. - Answer-B. One-inch pressure sore draining serous fluid.
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