Fundamentals of Nursing HESI

Correct Answer: B

Rationale: The correct action for the nurse to take is to give information about advance directives to the client. By providing this information, the nurse empowers the client to make an informed decision about their care preferences. Choice A is incorrect because simply recording the lack of advance directive does not address the client's need for information. Choice C is incorrect because assuming the client wishes a full code without discussing it with them is not appropriate and may not align with the client's wishes. Choice D is incorrect as the nurse should directly address the issue with the client rather than involving another staff member.

Correct Answer: B

Rationale: When evaluating the care of an immobilized patient, the nurse should focus on assessing outcomes and response to nursing care. By comparing the patient's actual outcomes with the outcomes identified during planning, the nurse can determine the effectiveness of the interventions implemented. This process allows for a comprehensive evaluation of the care provided. Choice A is incorrect because the satisfaction of the interdisciplinary team does not directly reflect the patient's outcomes and response to care. Choice C is incorrect as it mainly focuses on the involvement of the patient's family and healthcare team, which may not provide a holistic evaluation of the patient's care. Choice D is incorrect as relying solely on objective data may lead to overlooking important subjective aspects of the patient's response and outcomes, which are also crucial in evaluating care effectively.

Correct Answer: D

Rationale: Checking the client's blood pressure and pulse deficit is essential before mobilizing a client out of bed, especially after surgery. This assessment helps ensure the client's stability and readiness for mobilization. Administering oxygen or pivoting the client without prior assessment could pose risks if the client is not medically stable. Helping the client lie back down without proper evaluation may delay necessary interventions if the client is indeed ready for mobilization.

Correct Answer: B

Rationale: The correct answer is to emphasize emptying the child's mouth in any case of possible poisoning. This action is crucial to prevent further ingestion of the poisonous substance. Choice A is incorrect because calling the Poison Control Center should be one of the first steps, not waiting until the situation is identified. Choice C is incorrect as moving the child may spread or exacerbate the effects of the toxic substance. Choice D is incorrect because inducing vomiting can be harmful if the poison is a hydrocarbon, as it may lead to aspiration.

Correct Answer: A

Rationale: Assisting the client in preparing questions is the most appropriate action as it helps ensure that all concerns are addressed during the provider's visit. By helping the client write down questions, the nurse empowers the client to actively participate in their care and communicate effectively with the provider. Reassuring the client, while well-intentioned, may not address the specific questions or fears the client has. Explaining the procedure in detail may not be what the client is seeking at this moment, as their primary concern is about the provider's actions. Directing the client to search for information online is not recommended as it may lead to confusion or misinformation, and the information may not be tailored to the client's specific situation.