Fundamentals of Nursing HESI

Correct Answer: A

Rationale: The most critical aspect for the nurse to include in the discharge plan for a client performing his own dressing changes at home following abdominal surgery is the demonstration of appropriate hand hygiene. Proper hand hygiene is essential to prevent the introduction of infection during dressing changes. While wound care technique, signs and symptoms of infection, and instructions for contacting the healthcare provider are all important components of the discharge plan, ensuring the client understands and practices proper hand hygiene is paramount to minimize the risk of infection. This choice takes precedence as it directly addresses infection prevention during the dressing changes, which is crucial for successful post-operative recovery.

Correct Answer: A

Rationale: During a standing assessment, the healthcare professional should observe the patient laterally. In a normal body alignment, the head is erect, and the spinal curves align in a reversed 'S' pattern, aiding in maintaining balance and posture. Choice B is incorrect because hips and shoulders should be level and not form an 'S' pattern when observed posteriorly. Choice C is incorrect as the position of the arms is not a key indicator of body alignment. Choice D is incorrect as the feet should be shoulder-width apart with toes pointing forward for optimal balance and stability.

Correct Answer: A

Rationale: A heart rate of 52 beats per minute is a critical finding in a client taking digoxin, as it may indicate digoxin toxicity. Digoxin can cause bradycardia as a side effect, and a heart rate of 52 bpm warrants immediate attention to prevent adverse outcomes. Monitoring and reporting changes in heart rate are crucial in clients on digoxin therapy to prevent serious complications. The other vital signs and laboratory values provided are within normal ranges or not directly associated with digoxin toxicity in this scenario, making them lower priority for immediate reporting.

Correct Answer: C

Rationale: The correct immediate action for a healthcare worker who has been stuck by an exposed needle is to wash the hands thoroughly with soap and water to reduce the risk of infection. This helps to remove any potential pathogens introduced by the needle stick. Looking up the policy on needle sticks (Choice A) is important but not the immediate action required. Contacting employee health services (Choice B) and notifying the supervisor and risk management (Choice D) are crucial steps to take, but they should follow the initial step of washing the hands to mitigate the risk of infection.

Correct Answer: A

Rationale: The correct answer is A: Washing dishes. Washing dishes is a lower-intensity activity that is suitable for a client recovering from lung cancer. This activity does not require significant physical exertion and allows the client to engage in a manageable task while still following the provider's instructions for lower-intensity activities. Choices B, C, and D involve more physical effort and may not be appropriate for a client recovering from lung cancer, as they require more energy and physical strain, which could hinder the recovery process.