2019 Rationales HESI TEST BANK MED

SURG Version 2
1. How should the patient’s wife cope with changes to this lifestyle? -Ask what she wants and
how she would participate in her husband’s care.
2. The UAP has lowered the head of the bed for a client on tube feeding. What is the nurse’s
priority action? -Priority intervention is to ensure client’s bed is elevated to reduce the risk for
aspiration.
3. What should the nurse put on the client before suctioning the oral cavity? -Protective gear
should be worn.
4. How should the nurse assess for a gag reflex? -Place tongue blade on back half of the
tongue.
5. Which position reduce the risk for injury to the client? -Feet positioned directly on the floor in
front of wheelchair.
6. Which mask is used? -The top edge of a surgical mask should be secured.
7. A client is approaching near death. What is the best response? -Listen and help goals
preserve sense of hopelessness.
8. What assessment for patient’s gait and posture ADLs? –Assess activity tolerance before
determining ability to perform ADLs.
9. What is the most therapeutic response when her boyfriend is visiting? –Broad opening that
encourages to talk.
10. Before administering pain medication, what assessment is used? –Pain level scale
11. A patient is at risk for metabolic syndrome associated with obesity and physical inactivity. –
Measurement of waist circumference (skill done by PN)
12. What may contraindicate function? -significant decrease in neurosensory function.
13. Patient with obstructive sleep apnea syndrome (OSAS). Which teaching is effective? –
Advice patient to avoid alcoholic beverages 3 hours prior to bedtime.
14. What is the first component of the critical thinking model? –Knowledge base
15. Nasal Cannula-Skin Breakdown –Assess for skin damage that may occur.
16. Clients inability to control the urinary spincter when the urge to urinate is felt. –bedside
commode 2 hour to train bladder.
17. Navaso people –Direct eye contact interview is respect.
18. Patient uses accessory muscles to breathe. What does this mean? –Indicates increase
respiratory effort by the client.
19. What should the nurse talk do first when speaking with patient? –Ask family members to
leave the room.