Hesi rn d446 adult II

Question 1: View

A 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?

A. Assess the pulses proximal to the fracture site. B. Assess the pin sites for signs of infection. C. Administer pain medication at designated intervals around the clock. D. Remove traction every shift and provide skin 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.

Question 2: View

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?

A. Corticosteroid cream was applied to eczema. B. A grandson and his new dog recently visited. C. Recently received an influenza immunization. D. An old friend with eczema came for a visit.

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.

Question 3: View

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?

A. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter. B. Medicate for pain and monitor vital signs according to protocol. C. Administer intravenous fluid bolus as prescribed by the healthcare provider. D. Encourage the client to splint the incision with a pillow to cough and deep breathe.

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.

Question 4: View

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?

A. Bronze pigmentation. B. Uneven hair distribution. C. Lower leg edema. D. Bounding peripheral pulse.

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.

Question 5: View

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?

A. Have the client sign the surgical and transfusion permits. B. Notify the healthcare provider of the client's medication history. C. Ensure that the potential for bleeding is explained to the client. D. Observe the heparin injection sites for signs of bruising.

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.

Question 6: View

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?

A. Monitor urine and stool for occult blood regularly. B. Ensure a large gauge catheter is used to obtain blood samples. C. Remove cold and frozen foods from dietary trays. D. Wrap bruised areas with elastic bandage dressings.

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.

Question 7: View

A client receives a prescription for 2 liters of lactated Ringer's IV to be infused over 20 hours. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

Explanation

Infusion rate (mL/hr) = Volume to be infused (mL) / Time (hr)

In this case:

Volume to be infused = 2 liters = 2000 mL
Time = 20 hours

Plugging the values into the formula:

Infusion rate = 2000 mL / 20 hours = 100 mL/hr

Question 8: View

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?

A. Elevated creatinine and blood urea nitrogen (BUN). B. Hypovolemia and electrocardiographic (ECG) changes. C. Uremic irritation of mucous membranes and skin surfaces. D. Side effects of total parenteral nutrition (TPN) and intralipids.

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.

Question 9: View

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?

A. Activity level of bowel sounds. B. Level and amount of physical activity. C. Color and consistency of feces. D. Eating patterns of dietary intake.

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.

Question 10: View

The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?

A. Hemoglobin levels. B. Red blood cell count. C. White blood cell count. D. Platelet count.

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.