Fundamentals of Nursing HESI

Correct Answer: B

Rationale: Obtaining printed information on insulin self-administration should be the nurse's first priority. This action ensures that the client has the necessary knowledge to safely self-administer insulin at home. Providing the client with printed information (Choice A) is essential to empower the client with the required knowledge before considering additional resources. Making a copy of the medication reconciliation form for the client (Choice C) is important for documentation purposes but not as urgent as ensuring the client's understanding of insulin administration. Determining the client's ability to afford insulin administration supplies (Choice D) is crucial but should follow after ensuring the client is equipped with the necessary information for safe self-administration.

Correct Answer: D

Rationale: The correct answer is D. Eating foods high in potassium can lead to hyperkalemia when taken with digoxin, indicating a need for further teaching. Choices A, B, and C are all correct statements that demonstrate understanding of digoxin therapy. Taking the pulse, maintaining a consistent dosing schedule, and avoiding antacids to prevent interactions with digoxin are all appropriate client responses.

Correct Answer: A

Rationale: The correct action for the nurse to take when the urine bag has not filled for 2 hours is to check if the tubing is kinked. Kinks in the tubing can obstruct the flow of urine from the catheter, leading to decreased drainage. Increasing the IV fluid rate is not the appropriate initial action in this situation as the primary concern is with the catheter drainage. Checking the catheter insertion site would be secondary to ensuring proper drainage. Contacting the healthcare provider is not necessary as the issue can often be resolved by checking for simple tubing obstructions first.

Correct Answer: B

Rationale: When initiating IV therapy in older adults, it is essential to use the tourniquet minimally or not at all to prevent potential injury to fragile skin or veins. The use of a tourniquet can lead to increased venous pressure and potentially cause vein damage in older adult clients. Choice A is incorrect because inserting the IV catheter without a tourniquet can make locating veins more challenging. Choice C is incorrect as inserting the IV catheter at a 45-degree angle is not a recommended practice and can increase the risk of complications. Choice D is incorrect because using a smaller gauge catheter may not be appropriate for older adults who may require a larger gauge catheter for adequate fluid administration.

Correct Answer: A

Rationale: The correct answer is A: Assault. Assault involves making threats or using actions that cause the client to fear harm. In this scenario, the AP's threat to use diapers next time the urinal is used improperly constitutes as assault. Choice B, Battery, involves intentional harmful or offensive touching without consent, which is not evident in the scenario. Choice C, False imprisonment, refers to restraining or restricting a client's freedom of movement, which is not occurring in this situation. Choice D, Invasion of privacy, involves violating a client's right to privacy, which is also not applicable here.