a 57 year old male client is scheduled to have a stress thallium test the following morning and is npo after midnight at 0130 he is agitated because h
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HESI RN

HESI Medical Surgical Practice Exam Quizlet

1. A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client?

Correct answer: D

Rationale: Being direct and explaining to the client that the test requires him to be NPO, is the most therapeutic statement because the nurse is responding to the client's question and providing him the reason why.

2. A nursing student is suctioning a client through a tracheostomy tube while a nurse observes. Which action by the student would prompt the nurse to intervene and demonstrate the correct procedure? Select all that apply.

Correct answer: A

Rationale: The correct suction pressure for an adult client with a tracheostomy tube is typically between 80 to 120 mm Hg. Suction should be applied intermittently during catheter withdrawal to avoid damaging the airway. Assessing breath sounds before suctioning is important to ensure the procedure is necessary. Placing the client in a supine position before suctioning can compromise their airway; instead, the head of the bed should be elevated to facilitate proper drainage and reduce the risk of aspiration. Therefore, setting the suction pressure to 60 mm Hg is incorrect and would prompt the nurse to intervene and correct the procedure.

3. A nurse teaches a client who is recovering from a nephrectomy secondary to kidney trauma. Which statement should the nurse include in this client’s teaching?

Correct answer: D

Rationale: Clients with one kidney need to avoid contact sports because the kidneys are easily injured. The client will not be required to restrict salt and fluids, end up on dialysis, or have new hypertension because of the nephrectomy.

4. A nurse is teaching a nursing student how to measure a carotid pulse. The nurse should tell the student to measure the pulse on only one side of the client’s neck primarily because:

Correct answer: D

Rationale: The correct answer is D. Applying pressure to both carotid arteries at the same time is contraindicated. Excess pressure to the baroreceptors in the carotid vessels could cause the heart rate and blood pressure to reflexively drop. Palpating both carotid pulses simultaneously could also interfere with the flow of blood to the brain, possibly causing dizziness and syncope. Choices A, B, and C are incorrect. It is necessary to use both hands to measure the carotid pulse accurately. Feeling dual pulsations does not lead to an incorrect measurement, and palpating both carotid pulses simultaneously does not occlude the trachea.

5. A client has just been scheduled for endoscopic retrograde cholangiopancreatography (ERCP). What should the nurse tell the client about the procedure? Select all that apply.

Correct answer: B

Rationale: The correct answer is that the ERCP procedure takes about 1 hour to complete. Informed consent is required before the procedure. Premedication for sedation may be necessary as sedation is commonly used during ERCP to keep the client comfortable. Food and fluids are withheld before the procedure to prevent aspiration and ensure a clear view during the procedure. Position changes may be necessary to facilitate the passage of the tube.

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