HESI Fundamentals 2023 Test Bank

Correct Answer: D

Rationale: Elevated temperature is the correct finding to report immediately in a client with a history of peptic ulcer disease and abdominal pain. This could indicate a perforation or worsening of the condition, requiring prompt medical attention. Positive bowel sounds (Choice A) are a normal finding and not a cause for concern. Rebound tenderness (Choice B) is concerning but does not require immediate attention compared to an elevated temperature. Increased appetite (Choice C) is not a red flag symptom for peptic ulcer disease and can be considered a positive sign, not requiring immediate attention.

Correct Answer: A

Rationale: The correct action is to commend the client for selecting a high biological value protein, as scrambled eggs provide a good protein source for clients with chronic renal failure. Protein is essential for maintaining muscle mass and overall health in these clients. Reminding the client to avoid protein is incorrect as it may lead to protein-energy malnutrition, which is a common concern in chronic renal failure. Suggesting orange juice for absorption is not relevant to the situation, as protein absorption is not a primary concern in this context. Encouraging the client to attend classes on dietary management of chronic renal failure is important for overall education but is not the immediate action needed in response to the client's breakfast choice.

Correct Answer: A

Rationale: The correct order for abdominal assessment is inspection, auscultation, percussion, and palpation. Inspection allows the nurse to visually assess the abdomen for any abnormalities or distension. Auscultation follows to listen for bowel sounds and vascular sounds. Percussion helps to assess the density of underlying structures and detect any abnormal masses. Palpation is performed last to assess tenderness, organ size, and detect any masses. Choices B, C, and D have the steps in the incorrect order, making them the wrong choices.

Correct Answer: A

Rationale: The correct first action for the nurse to take is to check the IV tubing for obstruction. This step is crucial in ensuring that the IV fluids are flowing properly and that there are no blockages preventing the correct infusion rate. Increasing the flow rate (Choice B) without confirming the tubing's status could lead to potential complications if there is indeed an obstruction. Changing the IV site (Choice C) is not the priority in this situation unless there are specific clinical indications. Notifying the physician (Choice D) can be done after checking the tubing for obstruction, as the physician may need to be informed depending on the findings.

Correct Answer: B

Rationale: The correct action for the nurse to take in this situation is to withhold the blood transfusion. The principle of autonomy ensures that a competent client has the right to refuse treatment, even if their decision conflicts with the wishes of their partner or family. Asking the client to consider a direct donation (Choice A) is not appropriate as it disregards the client's autonomy and religious beliefs. Requesting a consultation with the ethics committee (Choice C) may be considered in complex ethical dilemmas, but in this case, the client's autonomy should be respected first. Asking the client's family to intervene (Choice D) is not appropriate as the client has the right to make their own healthcare decisions based on their religious beliefs.