During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report?- Skildor

Question 1 of 5

During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report?

A. The occurrence of any episodes of sleep apnea B. The child's blood pressure, pulse, and respirations C. Length of rapid eye movement (REM) sleep that the child is experiencing D. Description of the family's home environment

Correct Answer: D

Rationale: In response to the mother's report, the nurse should assess the family's home environment first to identify any factors that may hinder the establishment of bedtime routines conducive to sleep. Factors such as noise, light, distractions, or other environmental aspects could be contributing to the child's difficulty falling asleep at a reasonable hour and waking up in the morning.

Question 2 of 5

At a motor vehicle collision site, a nurse applies pressure to a groin wound that is bleeding profusely until emergency personnel arrive. Subsequently, the client undergoes leg amputation and sues the nurse for malpractice. What is the most likely outcome of this lawsuit?

A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case. B. The lawsuit may be settled out of court, but the nurse's license is unlikely to be revoked. C. There will be no judgment against the nurse, as their actions were protected under the Good Samaritan Act. D. The client will win because the four elements of negligence (duty, breach, causation, and damages) cannot be proved.

Correct Answer: C

Rationale: The Good Samaritan Act shields healthcare professionals who act in good faith and offer reasonable care from malpractice claims, irrespective of the client's outcome. In this scenario, the nurse stopping to render aid at the accident scene and applying pressure to the bleeding groin wound would likely be covered by the Good Samaritan Act, protecting the nurse from legal repercussions related to the subsequent leg amputation.

Question 3 of 5

When suctioning a tracheostomy, which action is most appropriate for the nurse to take?

A. Use a sterile tube each time and suction for 30 seconds. B. Use sterile technique and turn the suction off as the catheter is introduced. C. Use clean technique and suction for 10 seconds. D. Discard the catheter at the end of every shift.

Correct Answer: B

Rationale: When suctioning a tracheostomy, it is crucial to use sterile technique to prevent infections. Turning off the suction as the catheter is introduced is important to avoid trauma and injury to the tracheal walls. This technique helps maintain the integrity of the tracheostomy site and ensures proper care for the patient.

Question 4 of 5

The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement?

A. Tell the UAP to use a larger cuff at the next scheduled assessment. B. Reassess the client's blood pressure using a larger cuff. C. Have the unit educator review this procedure with the UAPs. D. Teach the UAP the correct technique for assessing blood pressure.

Correct Answer: B

Rationale: The most important action is to ensure that an accurate BP reading is obtained. The nurse should reassess the blood pressure with the correct size cuff (B) to obtain an accurate reading. Postponing reassessment (A) could lead to inaccurate results. While (C and D) are important actions for education and quality improvement, they are not as critical as obtaining an accurate blood pressure reading in this situation.

Question 5 of 5

The healthcare professional retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM 6 hours PRN for severe pain. How many mL should the healthcare professional administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth)

A. 0.8 mL B. 0.75 mL C. 0.7 mL D. 0.9 mL

Correct Answer: A

Rationale: To calculate the mL to administer, divide the ordered dose (3 mg) by the concentration (4 mg/mL). 3 mg � 4 mg/mL = 0.75 mL. Rounding to the nearest tenth, the correct dose to administer is 0.8 mL.

HESI Fundamentals

Skildor

HESI RN

HESI RN

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