Fundamentals of Nursing Final

BSN 225 HESI RN Specialty Fundamentals of Nursing Final Exam (Latest Update 2024 / 2025) Questions & Answers |100% Correct | Grade A - Nightingale

Question:

The adult daughter of an older client has been instructed on how to administer insulin to the client. Which observation indicates that the nurse needs to provide further instructions to the daughter?

• air is injected into the insulin vial before withdrawing the prescribed

amount

• alcohol swab is used to cleanse the skin before injecting
• the area of the injection is not massaged after administering the injection
• the deltoid muscle region is selected as the site for injection

Answer:

• the deltoid muscle region is selected as the site for injection

Rationale:

Insulin should be administered into the subQ tissue and not the muscle.

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Question:

During morning report the night nurse reports that an 86-year-old client often becomes confused, anxious, or is found pacing their room overnight.The client is also intermittently disoriented to date, time, and/or place. Based on this client's behavior, which intervention should the day nurse implement> (Select all that apply).

• obtain a prescription for melatonin or another sleep aid.
• ensure the client's room is dark and quiet during sleep hours.
• limit stimulating food, drink, or activities in the late afternoon and evening

hours

• keep the client active during the day with ambulation as tolerated and

structured activities

• establish a predictable daily routine that includes bedtime, waking, meals,

and daily activities.

Answer:

• limit stimulating food, drink, or activities in the late afternoon and evening

hours

• keep the client active during the day with ambulation as tolerated and

structured activities

• establish a predictable daily routine which includes bedtime, waking,

meals, and daily activities.

Rationale:

Management of sundowning behavior is targeted toward establishing routines, providing an environment suited to sleeping, and easing the symptoms of sundowning.

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Question:

The nurse establishes the nursing diagnosis of "impaired activity tolerance" for a client in an acute rehab facility who is recovering from hemicolectomy with colostomy surgery. What did the nurse observe?

• client asks spouse to perform stoma care and assist with feeding
• client rates pain score as 8/10 during physical therapy
• client's heart rate remains elevated 5 minutes after returning from the

bathroom

• client refuses to participate in scheduled group activities.

Answer:

• client's heart rate remains elevated 5 minutes after returning from the

bathroom

Rationale:

An elevated heart rate that remains elevated 5 minutes after completing an activity of mild intensity, such as ambulating to the bathroom, is an objective sign of activity intolerance.

Question:

PAST MEDICAL HX

Type II DM Stage 3 chronic kidney disease HTN Hyperlipidemia Osteoarthritis 3 / 4

Constipation

MEDICATIONS

Metformin 1000 mg PO q12h Naproxen 250 mg PO q6h PRN Spironolactone 50 mg PO qday Captopril 75 mg PO bid Pravastatin 40 mg PO qday Psyllium 5 grams PO qday

The nurse is reviewing appropriate food selections with a client. Which food item should the nurse encourage the client to remove from their lunch tray?

• steamed spinach
• baked chicken
• whole kernel corn
• medium-size apple

Answer:

• steamed spinach

Rationale:

Evaluation of the client's lunch choices reveals a portion of steamed spinach.Steamed spinach is high in potassium should be removed from the client's lunch tray.

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