Question

Which is the primary goal when planning nursing care for a client with degenerative joint disease (DJD?

Answer 1

Correct Answers:

Achieve satisfactory pain control.

Rationale :

🦴Degenerative joint disease (DJD), also known as osteoarthritis, primarily involves the deterioration of joint cartilage, which leads to chronic pain, stiffness, and reduced mobility.

💊The most immediate and impactful goal of care is pain control, as unmanaged pain directly affects the client’s ability to perform daily activities and reduces quality of life.

🛌While rest, stress management, and infection prevention are supportive, they are not the central priority in DJD care unless another condition complicates the clinical picture.

🧩Effective pain management allows for increased mobility, which in turn promotes better circulation, joint function, and emotional well-being, making it the foundation of nursing interventions for DJD.

📌Core Message

The primary focus in managing degenerative joint disease is to achieve pain control, which directly improves mobility and quality of life.

Answer 2

Correct Answers:

Ask the client to describe the pain.

Rationale :

🗣️The most accurate way to assess the quality of pain is through the client’s own description, as pain is a subjective experience that varies widely in character and perception.

📋Asking the client to describe the pain helps the nurse determine pain quality (e.g., aching, burning, sharp, throbbing), which is essential for appropriate intervention and diagnosis.

👁️Observing body language or movement may offer clues about pain presence or severity, but it cannot define pain quality, making it less specific for this purpose.

🔢Providing a numeric pain scale measures pain intensity, not pain quality, which is a different and equally important aspect of pain assessment.

🧩Identifying effective relief measures is part of pain management planning, not initial assessment of pain characteristics.

📌Core Message

Understanding pain quality in osteoarthritis requires asking the client to describe their pain, as this guides accurate assessment and treatment planning.

Answer 3

Correct Answers:

Discuss ethical concerns about placebo use with the healthcare provider.

Rationale :

⚖️Administering a placebo without the client’s knowledge violates ethical principles, especially autonomy and informed consent, making it essential for the nurse to address concerns directly with the provider.

🧑‍⚕️The nurse has a duty to advocate for ethical care and should clarify the rationale for the prescription while expressing concern about deception and client rights.

🚫Giving a placebo without disclosing its nature misleads the client and undermines trust in the nurse-client relationship, which is inconsistent with professional nursing standards.

🗣️Telling the client about the placebo before verifying and resolving the issue with the provider can create confusion or distrust, especially if the provider has not documented full disclosure.

📣Refusing to administer without communication is not the best first action; instead, collaboration and clarification help resolve the issue professionally and ethically.

📌Core Message

The nurse must prioritize ethical care by discussing placebo use directly with the provider to ensure client rights and informed consent are upheld.

Answer 4

Correct Answers:

Obtain a clean, voided urine specimen for analysis.

Rationale :

🧪A new onset of urinary incontinence in an older adult warrants assessment for a reversible cause, and urinary tract infection (UTI) is a common culprit.

🔍Collecting a clean-catch urine specimen allows for identification of infection, hematuria, or other urinary abnormalities, which helps guide further treatment.

📉Bladder training evaluation is premature without identifying underlying causes, as interventions should follow a thorough assessment.

🧴Providing absorbent products may help with comfort but does not address the source of the incontinence and may delay diagnosis.

💧Encouraging fluid intake can be helpful once infection is ruled out, but should not be the first step before diagnostic evaluation.

📌Core Message

For new urinary incontinence, the priority is to assess for possible infection by obtaining a clean urine specimen before initiating any treatment.

Answer 5

Correct Answers:

Position bedside table for client to lean across.

Rationale :

🪑Clients with acute pancreatitis often experience pain relief by sitting upright and leaning forward, a position that reduces intra-abdominal pressure and minimizes stimulation of the inflamed pancreas.

📦Providing a bedside table to lean across supports this preferred posture, promoting both physical comfort and respiratory ease while maintaining safety.

🛏️Strict bed rest is not necessary once analgesia and antiemetics are administered, especially if the client is more comfortable in an upright position.

📉Reverse Trendelenburg or placing the bed at 90 degrees may not be as stable or comfortable as a supported lean-forward position and may cause postural instability.

🧍‍♀️Supporting the client’s self-directed pain relief posture is part of client-centered care, and reinforces their autonomy in managing symptoms effectively.

📌Core Message

When managing pancreatitis pain, allow the client to lean forward, and use a bedside table for support to facilitate the most comfortable and effective position.

Answer 6

Correct Answers:

Apply the client's positive airway pressure device.

Rationale :

💤Clients with obstructive sleep apnea (OSA) are at high risk for respiratory depression, especially when given opioids, which suppress the central respiratory drive.

🛏️Applying the client’s positive airway pressure (PAP) device, such as CPAP or BiPAP, ensures the airway remains open during sleep or rest and reduces apnea episodes, especially under opioid influence.

📉Raising the head of the bed can assist breathing but is not sufficient alone to prevent airway collapse in OSA.

🦷Removing dentures is unnecessary and may reduce the structural integrity of the airway if the client is used to sleeping with them.

🛡️Raising side rails promotes safety but does not address the primary risk, which is respiratory compromise, making it a lower priority in this context.

📌Core Message

For clients with OSA receiving opioids, applying the positive airway pressure device is the most important step to prevent respiratory depression and maintain airway patency.

Answer 7

Correct Answers:

Question the client about the frequency of falls in recent months.

Rationale :

🦵Assessing the frequency of recent falls is a critical component of a functional assessment, especially in older adults who are at risk for mobility limitations and injury.

📉Falls can indicate declining physical function, balance issues, medication effects, or home environment hazards, all of which are essential to address during rehabilitation planning.

🧠Asking about sundowning relates more to cognitive assessment for dementia or delirium and is not central to functional capacity.

🛏️Encouraging stillness during the assessment would limit the nurse’s ability to evaluate movement, balance, and transfers, which are essential parts of a functional status evaluation.

🗝️Values clarification for end-of-life care is important but is more appropriate during advanced care planning, not a functional rehabilitation intake.

📌Core Message

In a functional assessment, it’s essential to evaluate fall history to understand the client’s mobility status and potential rehabilitation needs.

Answer 8

Correct Answers:

Question the client about the frequency of falls in recent months.

Rationale :

🦴Recent falls are a key indicator of declining physical function and are directly tied to a client’s mobility, balance, strength, and risk for injury, which are central to functional assessment.

📊Identifying how often the client has fallen helps guide the rehabilitation plan, including physical therapy needs, home safety modifications, and fall prevention strategies.

🧠Questions about sundowning pertain more to cognitive or neuropsychiatric evaluation, not the physical abilities central to a functional assessment.

🛌Instructing the client to lie still hinders the nurse’s ability to evaluate movement, transfers, gait, and independence in ADLs, which are essential elements of functional status.

📝Discussing end-of-life values is important but falls under advance care planning, not the immediate goal of determining the client’s physical capabilities for rehab.

📌Core Message

To assess functional ability, the nurse should ask about fall frequency, as this reveals critical information about mobility, safety, and rehab needs.

Answer 9

Correct Answers:

Urinary output of 30 to 60 mL/hr.

Rationale :

💧Potassium is excreted through the kidneys, so assessing urine output is essential to determine if the client can safely excrete excess potassium and avoid hyperkalemia.

🩸Before administering IV potassium, the nurse must confirm adequate renal function, and a urinary output of at least 30 mL/hr is the minimum safe threshold.

📉Serum glucose is important in monitoring diabetic ketoacidosis (DKA) treatment, but it does not guide potassium replacement safety.

🧪Magnesium levels are related to overall electrolyte balance but are not the priority assessment before starting potassium-containing fluids.

💉Catheter size affects infusion rate and access quality but is not the most important factor when evaluating for potassium chloride administration safety.

📌Core Message

Before administering IV potassium, the nurse must verify adequate urine output to ensure the kidneys can excrete potassium and prevent life-threatening hyperkalemia.

Answer 10

Correct Answers:

Pull the pinnae up and back to administer the drops.

Rationale :

👂In adults, the ear canal is angled, so the correct technique to straighten it for optimal medication delivery is to pull the pinna up and back.

🧴This positioning allows the drops to flow properly into the external auditory canal and ensures maximum contact with the infected area.

🪑Keeping the head upright during administration can cause the drops to run out of the ear and reduce their effectiveness.

❄️Ear drops should be warmed to body temperature, not cooled, to prevent dizziness or discomfort during administration.

🚫Inserting the dropper tip into the ear canal risks injury and contamination; the dropper should be held just above the ear opening instead.

📌Core Message

For adult ear drop administration, always pull the pinna up and back to straighten the ear canal and ensure proper medication flow.

HESI Exit (RN) 2023 Exam-3

No.

1 :
Which is the primary goal when planning nursing care for a client with degenerative joint disease (DJD?

2 :
The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking because of increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?

3 :
The health care provider prescribes a placebo instead of pain medication. Which intervention should the nurse implement?

4 :
An older adult client arrives at the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement?

5 :
A client diagnosed with pancreatitis is reporting severe epigastric pain and intense nausea. After the nurse administers a narcotic analgesic and an antiemetic, the client insists on sitting up and leaning forward. Which action should the nurse implement?

6 :
The nurse places an opioid patch on the chest of a client with intractable pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?

7 :
An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

8 :
An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

9 :
A client with type 1 diabetes mellitus (DM) is admitted in diabetic ketoacidosis. Treatment is initiated, and the nurse is preparing to administer IV fluids containing potassium chloride. Which assessment data is most important for the nurse to obtain before starting the infusion?

10 :
The healthcare provider prescribes ear drops to an adult client with an ear infection. Which teaching should the nurse provide?

HESI Exit (RN) 2023 Exam-3

No.

1 : Which is the primary goal when planning nursing care for a client with degenerative joint disease (DJD?

2 : The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking because of increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?

3 : The health care provider prescribes a placebo instead of pain medication. Which intervention should the nurse implement?

4 : An older adult client arrives at the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement?

5 : A client diagnosed with pancreatitis is reporting severe epigastric pain and intense nausea. After the nurse administers a narcotic analgesic and an antiemetic, the client insists on sitting up and leaning forward. Which action should the nurse implement?

6 : The nurse places an opioid patch on the chest of a client with intractable pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?

7 : An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

8 : An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

9 : A client with type 1 diabetes mellitus (DM) is admitted in diabetic ketoacidosis. Treatment is initiated, and the nurse is preparing to administer IV fluids containing potassium chloride. Which assessment data is most important for the nurse to obtain before starting the infusion?

10 : The healthcare provider prescribes ear drops to an adult client with an ear infection. Which teaching should the nurse provide?

1 :
Which is the primary goal when planning nursing care for a client with degenerative joint disease (DJD?

2 :
The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking because of increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?

3 :
The health care provider prescribes a placebo instead of pain medication. Which intervention should the nurse implement?

4 :
An older adult client arrives at the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement?

5 :
A client diagnosed with pancreatitis is reporting severe epigastric pain and intense nausea. After the nurse administers a narcotic analgesic and an antiemetic, the client insists on sitting up and leaning forward. Which action should the nurse implement?

6 :
The nurse places an opioid patch on the chest of a client with intractable pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?

7 :
An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

8 :
An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

9 :
A client with type 1 diabetes mellitus (DM) is admitted in diabetic ketoacidosis. Treatment is initiated, and the nurse is preparing to administer IV fluids containing potassium chloride. Which assessment data is most important for the nurse to obtain before starting the infusion?

10 :
The healthcare provider prescribes ear drops to an adult client with an ear infection. Which teaching should the nurse provide?