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HESI l Med l Surg l Exam l | l Questions l and l
Verified l Answers l with l Rationales| l 100% l
Correct| l 2025 / l 2026 l Newly l Updated
QUESTION
Whichl statementl madel byl al clientl withl chronicl pancreatitisl indicatesl thatl furtherl educationl isl needed? A.l Il willl cutl backl onl smokingl cigarettesl daily. B.l Il willl avoidl drinkingl caffeinatedl beverages. C.l Il willl restl frequentlyl andl avoidl vigorousl exercise. D.l Il willl eatl al bland,l low-fat,l high-proteinl diet. Answer: A Tol preventl exacerbationsl ofl chronicl pancreatitis,l clientsl shouldl bel instructedl tol avoidl nicotinel entirely.l Additionall teachingl includesl avoidingl caffeinatedl beverages,l restingl frequentlyl asl needed,l andl eatingl al blandl dietl lowl fatl andl highl inl protein.
QUESTION
Thel nursel isl teachingl al femalel clientl whol usesl al contraceptivel diaphragml aboutl reducingl thel riskl forl toxicl shockl syndromel (TSS).l Whichl informationl shouldl thel nursel include?l (Selectl alll thatl apply.) A.l Removel thel diaphragml immediatelyl afterl intercourse. B.l Washl thel diaphragml withl anl alcoholl solution. C.l Usel thel diaphragml tol preventl conceptionl duringl thel menstruall cycle. D.l Dol notl leavel thel diaphragml inl placel longerl thanl 8 l hoursl afterl intercourse. E.l Replacel thel oldl diaphragml everyl 3 l months. Answer: D,l E Thel diaphragml needsl tol remainl againstl thel cervixl forl 6 l tol 8 l hoursl tol preventl pregnancyl butl shouldl notl remainl forl longerl thanl 8 l hoursl tol avoidl thel riskl ofl toxicl
shockl syndrome.l Thel diaphragml shouldl bel replacedl everyl 3 l monthsl tol maintainl integrity.
QUESTION
Al malel clientl whol smokesl twol packsl ofl cigarettesl al dayl statesl hel understandsl thatl smokingl cigarettesl isl contributingl tol thel difficultyl thatl hel andl hisl wifel arel havingl inl gettingl pregnantl andl wantsl tol knowl ifl otherl factorsl couldl bel contributingl tol theirl difficulty.l Whatl informationl isl bestl forl thel nursel tol provide?l (Selectl alll thatl apply.) A.l Marijuanal cigarettesl dol notl affectl sperml count. B.l Alcoholl consumptionl canl causel erectilel dysfunction. C.l Lowl testosteronel levelsl affectl sperml production. D.l Cessationl ofl smokingl improvesl generall healthl andl fertility. E.l Obesityl hasl nol effectl onl sperml production. Answer: B,l C,l D Usel ofl tobacco,l alcohol,l andl marijuanal mayl affectl sperml counts.l Sperml countl isl alsol negativelyl affectedl byl lowl testosteronel levelsl andl obesity.
QUESTION
Al clientl isl newlyl diagnosedl withl diverticulosis.l Thel registeredl nursel (RN)l isl assessingl thel client'sl basicl knowledgel aboutl thel diseasel process.l Whichl statementl byl thel clientl conveysl anl understandingl ofl thel etiologyl ofl diverticula? A.l Overl usel ofl laxativesl forl bowell regularityl resultl inl lossl ofl peristalticl tone. B.l Inflammationl ofl thel colonl mucosal causel growthsl thatl protrudel intol thel colonl lumen. C.l Diverticulosisl isl thel resultl ofl highl fiberl dietl andl sedentaryl lifel style. D.l Chronicl constipationl causesl weakeningl ofl colonl walll whichl resultl inl out-pouchingl sacs. Answer: D Al clientl whol hasl chronicl constipationl oftenl strainsl tol passl constipatedl stooll whichl increasesl intestinall pressurel thatl weakensl thel intestinall wallsl andl causesl out-pouchingl sacs,l calledl diverticulal whichl commonlyl occurl inl thel sigmoid.
A.l Severel fluidl andl electrolytel imbalances. B.l Metabolicl acidosis. C.l Ribbon-likel stools. D.l Intermittentl lowerl abdominall cramping. Answer: A Amongl thel findingsl characteristicl ofl al smalll bowell obstructionl isl thel presencel ofl severel fluidl andl electrolytel imbalances.
QUESTION
Whichl clientl shouldl thel nursel recognizel asl mostl likelyl tol experiencel sleepl apnea? A.l Middle-agedl femalel whol takesl al diureticl nightly. B.l Obesel olderl malel clientl withl al short,l thickl neck. C.l Adolescentl femalel withl al historyl ofl tonsillectomy. D.l School-agedl malel withl al historyl ofl hyperactivityl disorder. Answer: B Sleepl apneal isl characterizedl byl lackl ofl respirationsl forl 10 l secondsl orl morel duringl sleepl andl isl duel tol thel lossl ofl pharyngeall tonel whichl allowsl thel pharynxl tol collapsel duringl inspirationl andl obstructsl airl flowl throughl thel nosel andl mouth.l Riskl factorsl whichl increasel thel conditionl ofl sleepl apneal include:l excessivel weight,l increasesl thel riskl 4 l timesl morel thanl normall weighingl individuals;l neckl circumference,l thickerl necksl havel narrowerl airways;l individualsl withl inheritedl narrowerl airways;l malesl inl generall arel morel pronel tol sleepl apnea;l femalesl riskl increasel withl beingl overweightl andl post- menopausal;l increasedl agel (geriatrics);l familyl history;l usel ofl alcohol,l sedativesl orl tranquilizers;l smokersl andl thosel whol sufferl froml nasall allergies.
QUESTION
Whichl milestonel indicatesl tol thel nursel successfull achievementl ofl youngl adulthood? A.l Demonstratesl al conceptualizationl ofl deathl andl dying. B.l Completesl educationl andl becomesl self-supporting. C.l Createsl al newl definitionl ofl selfl andl rolesl withl others. D.l Developsl al strongl needl forl parentall supportl andl approval.
Answer: B Transitioningl throughl youngl adulthoodl isl characterizedl byl establishingl independencel asl anl adult,l andl includesl developmentall tasksl suchl asl completingl education,l beginningl al career,l andl becomingl self-supporting
QUESTION
Whichl postmenopausall client'sl complaintl shouldl thel nursel referl tol thel healthcarel provider? A.l Breastsl feell lumpyl whenl palpated. B.l Historyl ofl whitel nipplel discharge. C.l Episodesl ofl vaginall bleeding. D.l Excessivel diaphoresisl occursl atl night. Answer: C Postmenopausall vaginall bleedingl mayl bel anl indicationl ofl endometriall cancer,l whichl shouldl bel reportedl tol thel healthcarel provider.
QUESTION
Thel nursel isl teachingl al femalel clientl aboutl thel bestl timel tol planl sexuall intercoursel inl orderl tol conceive.l Whichl informationl shouldl thel nursel provide? A.l Twol weeksl beforel menstruation. B.l Vaginall mucousl dischargel isl thick. C.l Lowl basall temperature. D.l Firstl thingl inl thel morning. Answer: A Ovulationl typicallyl occursl 14 l daysl beforel menstruationl beginsl duringl al typicall 28 l dayl cycle.l Sexuall intercoursel shouldl occurl withinl 24 l hoursl ofl ovulationl forl anl increasedl chancel ofl conceptionl tol occur.l Highl estrogenl levelsl occurl duringl ovulationl andl increasel thel vaginall mucousl membranel characteristicsl tol becomel morel "slippery"l andl stretchy,l
QUESTION
Whichl findingl shouldl thel nursel identifyl asl mostl significantl forl al clientl diagnosedl withl polycysticl kidneyl diseasel (PKD)? A.l Hematuria. B.l 2 l poundsl weightl gain. C.l 3+l bacterial inl urine. D.l Steady,l dulll flankl pain. Answer: C Urinaryl tractl infectionsl (UTI)l forl al clientl withl polycysticl kidneyl diseasel (PKD)l requirel promptl antibioticl therapyl tol preventl renall damagel andl scarringl whichl mayl causel furtherl progressionl ofl thel diseasel sol bacterial inl thel urinel wouldl bel significantl finding.
QUESTION
Thel nursel isl planningl carel forl al clientl withl newlyl diagnosedl diabetesl mellitusl thatl requiresl insulin.l Whichl assessmentl shouldl thel nursel identifyl beforel beginningl thel teachingl session? A.l Presentl knowledgel relatedl tol thel skilll ofl injection. B.l Intelligencel andl developmentall levell ofl thel client. C.l Willingnessl ofl thel clientl tol learnl thel injectionl sites. D.l Financiall resourcesl availablel forl thel equipment. Answer: C Ifl al clientl isl incapablel orl doesl notl wantl tol learn,l itl isl unlikelyl thatl learningl willl occur,l sol motivationl isl thel firstl factorl thel nursel shouldl assessl beforel teaching.
QUESTION
Whenl providingl dischargel teachingl forl al clientl withl osteoporosis,l thel nursel shouldl reinforcel whichl homel carel activity? A.l Al dietl lowl inl phosphates. B.l Skinl inspectionl forl bruising. C.l Exercisel regimen,l includingl swimming.
D.l Eliminationl ofl hazardsl tol homel safety. Answer: D Discussionl aboutl falll preventionl strategiesl isl imperativel forl thel dischargedl clientl withl osteoporosis.l Advicel aboutl safetyl measuresl inl thel homel shouldl bel providedl suchl asl thel eliminationl ofl throwl rugsl andl properl lightingl tol minimizel tripl hazardsl andl falls.
QUESTION
Al clientl withl gastroesophageall refluxl diseasel (GERD)l hasl beenl experiencingl severel refluxl duringl sleep.l Whichl recommendationl byl thel nursel isl mostl effectivel tol assistl thel client? A.l Losingl weight. B.l Decreasingl caffeinel intake C.l Avoidingl largel meals. D.l Raisingl thel headl ofl thel bedl onl blocks. Answer: D Raisingl thel headl ofl thel bedl onl blocksl (reversel Trendelenburgl position)l tol reducel refluxl andl subsequentl aspirationl isl thel mostl non-pharmacologicall effectivel recommendationl forl al clientl experiencingl severel gastroesophageall refluxl duringl sleep.
QUESTION
Thel nursel isl assistingl al clientl outl ofl bedl forl thel firstl timel afterl surgery.l Whichl actionl shouldl thel nursel dol first? A.l Placel al chairl atl al rightl anglel tol thel bedside. B.l Encouragel deepl breathingl priorl tol standing. C.l Helpl thel clientl tol sitl andl danglel legsl onl thel sidel ofl thel bed. D.l Allowl thel clientl tol sitl withl thel bedl inl al highl Fowler'sl position. Answer: D
QUESTION
Duringl anl interviewl withl al clientl planningl electivel surgery,l thel clientl asksl thel nurse,l "Whatl isl thel advantagel ofl havingl al preferredl providerl organizationl insurancel plan?"l Whichl responsel isl bestl forl thel nursel tol provide? A.l Neitherl planl allowsl selectionsl ofl healthcarel providersl orl hospitals. B.l Therel arel fewerl healthcarel providersl tol choosel froml thanl inl anl HMOl plan. C.l Anl individuall mayl selectl healthcarel providersl froml outsidel ofl thel PPOl network. D.l Anl individuall canl becomel al memberl ofl al PPOl withoutl belongingl tol al group. Answer: C Thel financiall implicationl ofl selectingl al providerl froml outsidel ofl thel networkl isl thel featurel mostl relevantl tol thel averagel consumer.l Thel nursel mustl havel knowledgel aboutl preferredl providerl organizationsl (PPOs),l whichl providesl thel optionl forl thel consumerl tol selectl al Healthcarel Providerl (HCP)l froml withinl thel PPOl networkl (in-network)l atl al reducedl costl versusl al higherl costl forl selectingl anl out-of-networkl HCP.
QUESTION
Al malel clientl receivesl al locall anestheticl duringl surgery.l Duringl thel post-operativel assessment,l thel nursel noticesl thel clientl isl slurringl hisl speech.l Whichl actionl shouldl thel nursel take? A.l Determinel thel clientl isl anxiousl andl allowl himl tol sleep. B.l Evaluatel hisl bloodl pressure,l pulse,l andl respiratoryl status. C.l Reviewl thel client'sl pre-operativel historyl forl alcoholl abuse. D.l Continuel tol monitorl thel clientl forl reactivityl tol anesthesia. Answer: B Slurredl speechl inl thel post-operativel clientl whol receivedl al locall anestheticl isl anl atypicall findingl andl mayl indicatel neurologicall deficitsl thatl requirel furtherl assessment,l sol obtainingl thel client'sl vitall signsl willl providel informationl aboutl possiblel cardiovascularl complications,l suchl asl stroke.
QUESTION
Al clientl whol isl sexuallyl activel withl severall partnersl requestsl anl intrauterinel devicel (IUD)l asl al contraceptivel method.l Whichl informationl shouldl thel nursel provide? A.l Usingl anl IUDl offersl nol protectionl againstl sexuallyl transmittedl diseasesl (STD),l whichl increasel thel riskl forl pelvicl inflammatoryl diseasel (PID). B.l Gettingl pregnantl whilel usingl anl IUDl isl commonl andl isl notl thel bestl contraceptivel choice. C.l Relyingl onl anl IUDl mayl bel al saferl choicel forl monogamousl partners,l butl al barrierl methodl providesl al betterl optionl inl preventingl STDl transmission. D.l Selectingl al contraceptivel devicel shouldl considerl choosingl al successfull methodl usedl inl thel past. Answer: A Thel usel ofl anl intrauterinel devicel (IUD)l providesl thel clientl withl nol protectionl froml sexuallyl transmittedl diseasesl (STD).
QUESTION
Al 20 - year-oldl femalel clientl callsl thel nursel tol reportl al lumpl shel foundl inl herl breast.l Whichl responsel isl thel bestl forl thel nursel tol provide? A.l "Checkl itl againl inl onel month,l andl ifl itl isl stilll therel schedulel anl appointment." B.l "Mostl lumpsl arel benign,l butl itl isl alwaysl bestl tol comel inl forl anl examination." C.l "Tryl notl tol worryl tool muchl aboutl it,l becausel usually,l mostl lumpsl arel benign." D.l "Ifl youl arel inl yourl menstruall periodl itl isl notl al goodl timel tol checkl forl lumps." Answer: B Thel nursel advisingl thel clientl tol comel inl providesl thel bestl responsel becausel itl addressesl thel client'sl anxietyl mostl effectivelyl andl encouragesl promptl andl immediatel actionl forl al potentiall problem.
QUESTION
Al 58 - year-oldl clientl whol hasl beenl post-menopausall forl fivel yearsl isl concernedl aboutl thel riskl forl osteoporosisl becausel herl motherl hasl thel condition.l Whichl informationl shouldl thel nursel offer?
Answer: A Bladderl controll isl al commonl probleml forl clientsl diagnosedl withl multiplel sclerosis.l Al clientl withl urinaryl retentionl shouldl receivel instructionsl aboutl self-catheterizationl tol preventl bladderl distention.
QUESTION
Al clientl withl al 16 - yearl historyl ofl diabetesl mellitusl isl havingl renall functionl testsl becausel ofl recentl fatigue,l weakness,l elevatedl bloodl ureal nitrogen,l andl seruml creatininel levels.l Whichl findingl shouldl thel nursel concludel asl anl earlyl symptoml ofl renall insufficiency? A.l Dyspnea. B.l Nocturia. C.l Confusion. D.l Stomatitis. Answer: B Asl thel glomerularl filtrationl ratel decreasesl inl earlyl renall insufficiency,l metabolicl wastel products,l includingl urea,l creatinine,l andl otherl substances,l suchl asl phenols,l hormones,l andl electrolytes,l accumulatel inl thel blood.l Inl thel earlyl stagel ofl renall insufficiency,l polyurial resultsl froml thel inabilityl ofl thel kidneysl tol concentratel urinel andl contributesl tol nocturia.
QUESTION
Whenl teachingl diaphragmaticl breathingl tol al clientl withl chronicl obstructivel pulmonaryl diseasel (COPD),l whichl informationl shouldl thel nursel provide? A.l Placel al smalll bookl orl magazinel onl thel abdomenl andl makel itl risel whilel inhalingl deeply. B.l Pursel thel lipsl whilel inhalingl asl deeplyl asl possiblel andl thenl exhalel throughl thel nose. C.l Wrapl al towell aroundl thel abdomenl andl pushl againstl thel towell whilel forcefullyl exhaling. D.l Placel onel handl onl thel chest,l onel handl thel abdomenl andl makel bothl handsl movel outward.
Answer: A Diaphragmaticl orl abdominall breathingl usesl thel diaphragml insteadl ofl accessoryl musclesl tol achievel maximuml inhalationl andl tol slowl thel respiratoryl rate.l Thel clientl shouldl protrudel thel abdomenl onl inhalationl andl contractl itl withl exhalation,l sol placingl al bookl orl magazine,l helpsl thel clientl visualizel thel risel andl falll ofl thel abdomen.
QUESTION
Duringl suctioning,l al clientl withl anl uncuffedl tracheostomyl tubel beginsl tol coughl violentlyl andl dislodgesl thel tracheostomyl tube.l Whichl actionl shouldl thel nursel implementl first? A.l Notifyl thel healthcarel providerl forl reinsertion. B.l Attemptl tol reinsertl thel tracheostomyl tube. C.l Positionl thel clientl inl al laterall positionl withl thel neckl extended. D.l Ventilatel client'sl tracheostomyl stomal withl al manuall bag-mask. Answer: B Thel nursel shouldl attemptl tol reinsertl thel tracheostomyl tubel byl usingl al hemostatl tol openl thel tracheostomyl orl byl graspingl thel retentionl suturesl (ifl present)l tol spreadl thel openingl andl insertl al replacementl tubel (withl itsl obturator)l intol thel stoma.l Oncel inl place,l thel obturatorl shouldl immediatelyl bel removed.
QUESTION
Al clientl isl admittedl forl furtherl testingl tol confirml sarcoidosis.l Whichl diagnosticl testl providesl definitivel informationl thatl thel nursel shouldl reportl tol thel healthcarel provider? A.l Lungl tissuel biopsy. B.l Positivel bloodl cultures. C.l Magneticl resonancel imagingl (MRI). D.l Computerizedl tomographyl (CT)l ofl thel thorax. Answer: A Sarcoidosisl isl anl inflammatoryl conditionl thatl isl characterizedl byl thel formationl ofl widespreadl granulomatousl lesionsl involvingl al pulmonaryl primaryl site.l Althoughl chestl
restorel anl effectivel cardiacl rhythm.l Thel automaticl defibrillatorl isl obviouslyl malfunctioning.
QUESTION
Thel nursel workingl inl al postoperativel surgicall clinicl isl assessingl al womanl whol hadl al leftl radicall mastectomyl forl breastl cancer.l Whichl factorl putsl thisl clientl atl greatestl riskl forl developingl lymphedema? A.l Shel sustainedl anl insectl bitel tol herl leftl arml yesterday. B.l Shel hasl lostl twentyl poundsl sincel thel surgery. C.l Herl healthcarel providerl nowl prescribesl al calciuml channell blockerl forl hypertension. D.l Herl hobbyl isl playingl classicall musicl onl thel piano. Answer: A Al radicall mastectomyl interruptsl lymphl flow,l andl thel increasedl lymphl flowl thatl occursl inl responsel tol thel insectl bitel increasesl thel riskl forl thel occurrencel ofl lymphedema.
QUESTION
Whichl interventionl shouldl thel nursel implementl forl al femalel clientl diagnosedl withl pelvicl relaxationl disorder? A.l Describel properl administrationl ofl vaginall suppositoriesl andl cream. B.l Encouragel thel clientl tol performl Kegell exercisesl 10 l timesl daily. C.l Explainl thel importancel ofl usingl condomsl whenl havingl sexuall intercourse. D.l Discussl thel importancel ofl keepingl al diaryl ofl dailyl temperaturel andl menstruall cyclel events. Answer: B Pelvicl relaxationl disordersl arel structurall disordersl resultingl froml weakeningl supportl tissuesl ofl thel pelvis.l Kegell exercisesl helpl strengthenl thel surroundingl muscles.
QUESTION
Whatl typesl ofl medicationsl shouldl thel nursel expectl tol administerl tol al clientl duringl anl acutel respiratoryl distressl episode? A.l Vasodilatorsl andl hormones. B.l Analgesicsl andl sedatives. C.l Anticoagulantsl andl expectorants. D.l Bronchodilatorsl andl steroids. Answer: D Besidesl supplementall oxygen,l al clientl withl acutel respiratoryl distressl syndromel (ARDS)l needsl medicationsl tol widenl airl passages,l increasel airl space,l andl reducel alveolarl membranel inflammation,l suchl asl bronchodilatorsl andl steroids.
QUESTION
Al 46 - year-oldl femalel clientl isl admittedl forl acutel renall failurel secondaryl tol diabetesl andl hypertension.l Whichl testl isl thel bestl indicatorl ofl adequatel glomerularl filtration? A.l Seruml creatinine. B.l Bloodl Ureal Nitrogenl (BUN). C.l Sedimentationl rate. D.l Urinel specificl gravity. Answer: A Creatininel isl al productl ofl musclel metabolisml thatl isl filteredl byl thel glomerulus,l andl bloodl levelsl ofl thisl substancel arel notl affectedl byl dietaryl orl fluidl intake.l Anl elevatedl creatininel stronglyl indicatesl nephronl loss,l reducingl filtration.
QUESTION
Healthcarel workersl mustl protectl themselvesl againstl becomingl infectedl withl HIV.l Thel Centerl forl Diseasel Controll hasl issuedl guidelinesl forl healthcarel workersl inl relationl tol protectionl froml HIV.l Thesel guidelinesl includel whichl recommendation? A.l Placel HIVl positivel clientsl inl strictl isolationl andl limitl visitors. B.l Wearl glovesl whenl comingl inl contactl withl thel bloodl orl bodyl fluidsl ofl anyl client. C.l Conductl mandatoryl HIVl testingl ofl thosel whol workl withl AIDSl clients. D.l Freezel HIVl bloodl specimensl atl - 70 l Fl tol killl thel virus.
andl latel menopause,l butl arel notl consideredl asl predictivel asl al positivel historyl ofl anl immediatel familyl memberl andl overl 40 l yearsl old.
QUESTION
Al clientl isl admittedl tol thel medicall intensivel carel unitl withl al diagnosisl ofl myocardiall infarction.l Thel client'sl historyl indicatesl thel infarctionl occurredl tenl hoursl ago.l Whichl laboratoryl testl resultl wouldl thel nursel expectl thisl clientl tol exhibit? A.l Elevatedl LDH. B.l Elevatedl seruml amylase. C.l Elevatedl CK-MB. D.l Elevatedl hematocrit. Answer: C Thel cardiacl isoenzymel CK-MBl (C)l isl thel onel ofl thel cardiacl markersl tol indicatel myocardiall damagel inl thel presencel ofl MIl symptomsl andl afterl al positivel troponin.l Thel troponinl levelsl willl elevatel withinl 2 - 3 l hoursl indicatingl myocardiall ischemia,l followedl byl thel CK-MBl cardiacl markersl withinl 6 - 9 l hours,l peakingl withinl 12 l tol 20 l hoursl afterl myocardiall infarctionl (MI).
QUESTION
Thel nursel isl assessingl al clientl whol smokesl cigarettesl andl hasl beenl diagnosedl withl emphysema.l Whichl findingl wouldl thel nursel expectl thisl clientl tol exhibit? A.l Al decreasedl totall lungl capacity. B.l Normall arteriall bloodl gases. C.l Normall skinl coloring. D.l Anl absencel ofl sputum. Answer: A Thel differentiationl betweenl thel "pinkl puffer"l andl thel "bluel bloater"l isl al well-knownl methodl ofl differentiatingl clientsl exhibitingl symptomsl ofl emphysemal (normall colorl butl puffingl respirations)l froml thosel exhibitingl symptomsl ofl chronicl bronchitisl (edematous,l cyanotic,l shallowl respirations).
QUESTION
Al splintl isl prescribedl forl nighttimel usel byl al clientl withl rheumatoidl arthritis.l Whichl statementl byl thel nursel providesl thel mostl accuratel explanationl forl usel ofl thel splints? A.l Preventionl ofl deformities. B.l Avoidancel ofl jointl trauma. C.l Reliefl ofl jointl inflammation. D.l Improvementl inl jointl strength. Answer: A Splintsl mayl bel usedl atl nightl byl clientsl withl rheumatoidl arthritisl tol preventl deformitiesl causedl byl musclel spasmsl andl contractures.
QUESTION
Al clientl whol wasl inl al motorl vehiclel collisionl wasl admittedl tol thel hospitall andl thel rightl kneel wasl placedl inl skeletall traction.l Thel nursel hasl documentedl thisl nursingl diagnosisl inl thel client'sl medicall record:l "Potentiall forl impairmentl ofl skinl integrityl relatedl tol immobilityl froml traction."l Whichl nursingl interventionl isl indicatedl basedl onl thisl diagnosisl statement? A.l Releasel thel tractionl q4hl tol providel skinl care. B.l Turnl thel clientl forl backl carel whilel suspendingl traction. C.l Providel backl andl skinl carel whilel maintainingl thel traction. D.l Givel backl carel afterl thel clientl isl releasedl froml traction. Answer: C Maintainingl skinl integrityl andl providingl backl carel isl difficultl whenl al clientl isl inl traction,l butl mustl bel performedl andl isl thel correctl interventionl tol maintainl thel client'sl skinl integrity.
QUESTION
Thel nursel assessesl al clientl withl advancedl cirrhosisl ofl thel liverl forl signsl ofl hepaticl encephalopathy.l Whichl findingl wouldl thel nursel considerl anl indicationl ofl progressivel hepaticl encephalopathy?
