Hesi rn d446 adult II
Total Questions : 45
Showing 25 questions, Sign in for moreA client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing plan of care?
Explanation
A. Assessing the pulses proximal to the fracture site is crucial for evaluating blood circulation to the affected limb and detecting potential complications such as compartment syndrome.
B. While monitoring pin sites for signs of infection is important, the priority is ensuring adequate circulation.
C. Administering pain medication is essential for comfort but does not address potential complications from skeletal traction.
D. Removing traction every shift is not advisable as it can compromise the alignment and healing of the fracture.
During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?
Explanation
A. While the use of corticosteroid cream is relevant to treatment, it does not indicate a new cause for symptom exacerbation.
B. The introduction of a new dog could be a potential allergen, triggering an exacerbation of the client's eczema symptoms.
C. Receiving an influenza immunization is unlikely to be related to eczema exacerbations and is not a common trigger.
D. An old friend with eczema does not present a direct cause for the current exacerbation and is less relevant to the client's current condition.
The nurse is caring for a client in the postanesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the vital signs as a heart rate of 140 beats/minute, respirations 26 breaths/minute, and a blood pressure 140/90 mm Hg. Which intervention is most important for the nurse to implement?
Explanation
A. The elevated heart rate and respirations suggest the client may be experiencing hypoxia, especially following a thoracotomy. Administering oxygen will help improve oxygen saturation levels and address potential respiratory distress.
B. While pain management is essential, the immediate concern is ensuring adequate oxygenation.
C. Administering IV fluids may be necessary but is secondary to ensuring the client's oxygenation.
D. Encouraging the client to splint and cough is important for preventing complications but does not address the immediate issue of vital signs indicating possible respiratory compromise.
The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of compromised peripheral arterial circulation of the lower extremity?
Explanation
A. Bronze pigmentation is often associated with venous insufficiency rather than arterial compromise.
B. Compromised peripheral arterial circulation can lead to decreased blood flow, resulting in uneven or diminished hair distribution on the lower extremities due to lack of nourishment to hair follicles.
C. Lower leg edema is more commonly associated with venous insufficiency rather than arterial insufficiency.
D. A bounding peripheral pulse indicates increased arterial pressure or volume, which is not consistent with compromised arterial circulation, where pulses are typically weak or absent.
The nurse is preparing a client for surgery who was admitted from the emergency department following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units SUBQ daily. Which nursing action is a priority?
Explanation
A. While having the client sign permits is important, it is not the priority action in this situation.
B. Notifying the healthcare provider about the client's current heparin therapy is critical, as it may influence the timing of surgery and the risk of excessive bleeding during and after the procedure.
C. While explaining the potential for bleeding is important, it should occur after ensuring the surgical team is aware of the heparin use.
D. Observing injection sites for bruising is relevant but does not address the immediate concern regarding heparin use and potential bleeding during surgery.
A client with leukemia is receiving chemotherapy. The nurse observes the client is weak, pale, and febrile. After reviewing the client's most recent laboratory results which reveals a platelet count of 25,000/mm3 (25 x 10^9/L), which intervention should the nurse include in the plan of care?
Explanation
A. Monitoring for occult blood in urine and stool is crucial in clients with low platelet counts to detect any potential bleeding early, as they are at increased risk of bleeding due to thrombocytopenia.
B. Using a large gauge catheter may be necessary for some procedures, but it is not the priority intervention regarding the client’s current state and platelet count.
C. Removing cold and frozen foods from dietary trays does not directly address the critical concern of bleeding associated with low platelet levels.
D. While protecting bruised areas is important, it is secondary to monitoring for active bleeding, which is more critical at this stage.
A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor?
Explanation
A. While elevated creatinine and BUN are important indicators of kidney function, in the diuretic phase, the focus shifts to monitoring for complications, particularly fluid and electrolyte balance.
B. Hypovolemia can occur due to excessive diuresis during the diuretic phase, which can lead to significant cardiovascular effects, including ECG changes related to electrolyte imbalances, particularly potassium levels.
C. Monitoring for uremic irritation is important but less critical than monitoring for hypovolemia and ECG changes that can lead to acute complications.
D. While monitoring for side effects of TPN is relevant, it is not the priority in the context of AKI transitioning phases where fluid and electrolyte balance are paramount.
The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?
Explanation
A. While bowel sounds can indicate gastrointestinal activity, they do not directly correlate with pain management or the underlying cause of abdominal discomfort in chronic pancreatitis.
B. The level and amount of physical activity may impact overall well-being but are less directly related to the management of abdominal pain from pancreatitis.
C. The color and consistency of feces can provide some information regarding pancreatic function and fat absorption but is not the most immediate factor affecting pain management.
D. Understanding the client’s eating patterns, including food triggers and timing, is crucial because certain foods can exacerbate abdominal pain in chronic pancreatitis. Dietary adjustments can significantly help manage symptoms and improve quality of life.
The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?
Explanation
A. Hemoglobin levels can indicate anemia but are not directly related to the presence of petechiae and ecchymosis, which suggest bleeding issues.
B. The red blood cell count is also important for understanding anemia but does not specifically address the bleeding disorders indicated by the client’s symptoms.
C. The white blood cell count provides information on the immune status but does not relate to bleeding manifestations.
D. The platelet count is critical to assess because petechiae and ecchymosis can be indicative of thrombocytopenia (low platelet count), which can lead to increased bleeding tendencies. Monitoring platelet levels will help determine the cause of these symptoms.
A client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling experienced worsens at night. Which client teaching should the nurse provide?
Explanation
A. Wearing braces or splints on both wrists at night helps to keep the wrists in a neutral position, preventing flexion that can worsen symptoms of carpal tunnel syndrome, particularly during sleep when the hands are more likely to be positioned in ways that exacerbate compression of the median nerve.
B. While notifying the healthcare provider is important if symptoms are severe, it is not the immediate teaching intervention the nurse should provide for symptom management.
C. Elevating the hands may help with swelling but is not the primary intervention for managing symptoms of carpal tunnel syndrome, especially pain and tingling.
D. Cold compresses may provide temporary relief but do not address the underlying issue of median nerve compression, which is better managed by using wrist braces.
The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?
Explanation
A. Selecting another finger is the best action to prevent discomfort and ensure an accurate blood sample. The reddened and engorged tip may indicate that milking the finger caused bruising or altered blood flow, which can affect the glucose reading.
B. Applying pressure to the site may be appropriate after collecting a sample, but it does not address the issue of obtaining an accurate sample from an engorged finger.
C. Assessing radial pulse volume is not relevant in this situation and does not address the problem at hand.
D. Collecting the blood sample from a reddened and engorged finger could yield an inaccurate result, so it is better to select a different finger.
An adult client who was recently diagnosed with glaucoma tells the nurse, "It feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?
Explanation
A. Avoiding frequent eye pressure measurements is not advisable; monitoring eye pressure is crucial in managing glaucoma.
B. Maintaining the prescribed eye drop regimen is the most important instruction because consistent use of these medications is critical to managing intraocular pressure and preventing vision loss associated with glaucoma.
C. While wearing prescription glasses can assist with vision, it does not address the underlying condition of glaucoma.
D. Eating a diet high in carotene is beneficial for overall eye health but does not directly impact the management of glaucoma. Regular use of prescribed eye drops is essential to prevent further damage to the optic nerve and potential blindness.
Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?
Explanation
A. Visible swelling of the neck may indicate other conditions, such as thyroid issues, but it is not a characteristic finding of Cushing's syndrome.
B. Warm, soft, moist, salmon-colored skin is more indicative of hyperthyroidism rather than Cushing's syndrome, which typically presents with thin, fragile skin.
C. A husky voice and hoarseness can occur due to various reasons, but they are not classic symptoms of Cushing's syndrome.
D. Central type obesity, characterized by a rounded face and thin extremities, is a hallmark feature of Cushing's syndrome, caused by excessive cortisol levels leading to fat redistribution.
A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next?
Explanation
A. Obtaining a sample of the drainage is not an immediate priority after evisceration; the patient's safety and stabilization come first.
B. Auscultating the abdomen for bowel sounds is important but secondary to addressing the immediate crisis of evisceration.
C. Preparing the client to return to the operating room is the priority action because evisceration indicates a surgical emergency that requires prompt intervention to repair the abdominal wall and prevent complications.
D. While additional sterile dressing supplies may be needed, addressing the evisceration takes precedence to prevent further injury and manage the patient’s condition.
Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?
Explanation
A. While sipping fluids with meals can help prevent discomfort, it is generally recommended to avoid drinking fluids during meals to minimize the risk of overfilling the stomach.
B. Reducing intake of fatty foods is important, but it is not as critical as managing portion sizes and meal frequency after gastric bypass surgery.
C. Eating small frequent meals is crucial after gastric bypass surgery because it helps manage the reduced stomach capacity and promotes better nutrient absorption while preventing dumping syndrome and discomfort.
D. Chewing slowly and thoroughly is a good practice to aid digestion, but it is not as essential as the need for portion control and meal frequency following the surgery.
An older adult client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?
Explanation
A. Clear, dark amber-colored urine may indicate dehydration or concentrated urine, which does not necessarily signify improvement in liver function or treatment efficacy.
B. A prothrombin time within normal limits may indicate improved liver function; however, it is not the primary goal of the treatment plan focused on managing ascites and fluid retention in cirrhosis.
C. Decreased abdominal girth is a key indicator of progress in managing fluid retention associated with cirrhosis, as the treatment plan aims to reduce ascites through a low sodium diet and albumin infusions.
D. Improved level of consciousness is essential for overall recovery but is not the primary measure of progress related to fluid management and treatment effects in this context.
The nurse is caring for a client after a coronary artery bypass graft surgery. The client is exhibiting pitting edema of the lower extremities and jugular venous distention with increased central venous pressure. Which condition should the nurse suspect the client is experiencing based on these findings?
Explanation
A. Internal bleeding typically presents with signs of hypovolemia, such as decreased blood pressure and increased heart rate, rather than pitting edema and jugular venous distention.
B. Right-sided heart failure is characterized by fluid overload, leading to symptoms like pitting edema in the extremities and jugular venous distention, which align with the findings observed in this client.
C. Left ventricular dysfunction primarily results in pulmonary congestion and respiratory distress rather than peripheral edema and jugular venous distention.
D. Cardiac tamponade may present with jugular venous distention, but it usually also involves hypotension and muffled heart sounds, which are not described in this scenario.
A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple lumen catheter for continuous bladder irrigation with normal saline is infusing, and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?
Explanation
A. Discontinuing the infusion may lead to increased clotting and potential obstruction of the catheter. Continuous bladder irrigation is essential to keep the bladder clear of clots and debris following surgery.
B. Manually irrigating the catheter can help clear any clots that may be obstructing the catheter, ensuring adequate drainage and preventing complications such as bladder distention or retention. This is the most immediate and appropriate action to take in response to the presence of clots.
C. Monitoring catheter drainage is important; however, it does not address the potential issue of clots obstructing the flow of urine, which is the priority concern in this scenario.
D. Decreasing the flow rate may not be beneficial and could lead to inadequate irrigation of the bladder, which could exacerbate clot formation and urinary retention.
The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment?
Explanation
A. Tenderness upon palpation and generalized erythema indicate skin irritation and possible sunburn, which are signs of overexposure to PUVA treatment. This finding suggests that the client may have received excessive ultraviolet exposure, leading to skin damage.
B. Thick skin plaques topped by silvery white scales are characteristic of psoriasis vulgaris itself, not a sign of overexposure to PUVA.
C. Requiring sunglasses because sunlight hurts the eyes may indicate sensitivity but is not a specific indicator of overexposure to PUVA treatment; it could relate to other issues such as underlying eye conditions.
D. Brown, rough, greasy, wart-like papules on the face are not typically associated with PUVA overexposure but could be related to other skin conditions or lesions.
The nurse is caring for a client who reports a sudden, severe headache and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. Which intervention should the nurse perform in the immediate management of the client?
Explanation
A. Administering aspirin is not appropriate at this time, as it may delay treatment for a stroke if that is the underlying cause.
B. Maintaining elevated positioning of the dependent joints is not a priority in this acute situation and does not address the immediate needs of the client showing signs of possible stroke.
C. Verifying laboratory tests like prothrombin time and platelet count is important but is not an immediate intervention that addresses the acute condition.
D. Starting two large bore IV catheters and reviewing criteria for IV fibrinolytic therapy is crucial because the client presents with signs of a potential stroke. Rapid identification and treatment are essential to improving outcomes in acute ischemic stroke cases.
The nurse is caring for a client who tests positive for the sexually transmitted infection (STI) gonorrhea. The client reports having sex with someone who has many partners. Which response should the nurse provide?
Explanation
A. While safe sex practices can reduce the risk of STIs, they do not eliminate the risk entirely, especially in cases where partners have multiple sexual partners.
B. Not all STIs are transmitted solely through sexual intercourse; some can be transmitted through other means, making this statement overly simplistic.
C. It's important to note that asymptomatic individuals can still be carriers of STIs, so this statement may give a false sense of security.
D. Teaching the importance of adhering to the medication regimen and ensuring follow-up appointments is critical in managing gonorrhea effectively and preventing complications or reinfection. This approach emphasizes the importance of treatment compliance and ongoing health management.
A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?
Explanation
A. Bradycardia and constipation are symptoms associated with hypothyroidism, not hyperthyroidism, indicating that the dosage may be too low rather than too high.
B. Muscle cramping and dry, flushed skin are not typical indicators of levothyroxine overdose and may reflect other underlying issues.
C. Palpitations and shortness of breath are symptoms indicative of hyperthyroidism, suggesting that the levothyroxine dosage may be too high, leading to an increased metabolic rate and cardiovascular stress.
D. Lethargy and lack of appetite are more consistent with under-treatment or hypothyroidism rather than an overdose of levothyroxine, which typically stimulates metabolic activity.
A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?
Explanation
A. Administering opioid and non-opioid medications together is an effective pain management strategy for severe pain. This approach can provide better pain relief by targeting different pain pathways and may reduce the total dosage of opioids needed, thus minimizing side effects.
B. Alternating IV and IM analgesic medications is not the best approach; instead, consistent pain management is necessary to keep pain levels under control.
C. Waiting until the pain score reaches 10 before administering the maximum dosage is inappropriate and could lead to inadequate pain control. Pain management should be proactive, not reactive.
D. While educating the client on narcotic dependency is important, it is not the priority intervention in this acute situation where pain control is essential. The immediate focus should be on effective pain relief.
The nurse is caring for a client who tests positive for the sexually transmitted infection (STI) gonorrhea. The client reports having sex with someone who has many partners. Which response should the nurse provide?
Explanation
A. While safe sex practices can significantly reduce the risk of STIs, they do not eliminate the risk entirely, especially with multiple partners involved.
B. This statement is misleading; not all STIs are transmitted solely through sexual intercourse, as some can also be transmitted through non-sexual means.
C. It is important to recognize that asymptomatic individuals can still be carriers of STIs; thus, this statement may provide false reassurance.
D. Teaching the client about the importance of following the medication regimen and attending follow-up appointments is critical for effective treatment of gonorrhea and preventing further transmission or complications. This approach prioritizes the client’s health and reinforces the need for responsible sexual practices.
The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?
Explanation
A. Encouraging physical activity, such as walking, is important for cardiovascular health, but it is not a measurable outcome related to the client's current condition of blurred vision and cardiovascular disease.
B. While educating the family about signs and symptoms is valuable, it does not directly address the client's health status or outcomes that can be measured.
C. A target blood pressure of less than 160/90 mm Hg does not adequately control hypertension and may still pose a risk to cardiovascular health, especially given the blurred vision, which could indicate possible complications.
D. Setting a goal for the client’s daily blood pressure to be less than 140/80 mm Hg is a clear, measurable outcome that indicates effective management of hypertension and promotes overall cardiovascular health. This target is aligned with current clinical guidelines for hypertension management.
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