a client is admitted with a diagnosis of chronic obstructive pulmonary disease copd exacerbation which intervention should the nurse implement first
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Nursing Elites

HESI RN

HESI Fundamentals Practice Test

1. A client is admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation. Which intervention should the nurse implement first?

Correct answer: B

Rationale: Administering oxygen via nasal cannula (B) is the priority intervention for a client with COPD exacerbation to improve oxygenation. In COPD exacerbation, there is impaired gas exchange leading to hypoxemia, making oxygen therapy the initial priority. Administering bronchodilators (A) helps with bronchodilation but should come after ensuring adequate oxygenation. Encouraging coughing and deep breathing (C) and positioning the client in high Fowler's position (D) are also beneficial interventions, but the first step is to address the oxygenation needs of the client.

2. A client with chronic renal failure is receiving epoetin alfa (Epogen). Which laboratory test should the nurse monitor to evaluate the effectiveness of this medication?

Correct answer: B

Rationale: The correct answer is B: Hemoglobin and hematocrit. These are the primary laboratory tests to monitor the effectiveness of epoetin alfa (Epogen) in treating anemia. White blood cell count (A), platelet count (C), and blood urea nitrogen (BUN) and creatinine (D) are not directly related to the effects of this medication. Epoetin alfa stimulates the production of red blood cells, so monitoring hemoglobin and hematocrit levels helps assess the response to the treatment.

3. Earlier this morning, an elderly Hispanic female was discharged to a LTC facility. The family members are now gathered in the hallway outside her room. What is the best action?

Correct answer: B

Rationale: In this situation, providing space and privacy for the family allows them to openly discuss their concerns regarding the client’s discharge. It respects the family's need for support, communication, and involvement in the decision-making process, ultimately fostering a more effective and compassionate care environment.

4. When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled 'opened' and dated 48 hours prior to the current date. Which is the best action for the nurse to take?

Correct answer: D

Rationale: When performing sterile wound care, it is essential to use only newly opened and unexpired solutions to maintain sterility and prevent infections. The normal saline solution obtained by the nurse is labeled 'opened' and dated 48 hours prior to the current date, making it no longer considered sterile. The best action for the nurse to take in this situation is to discard the saline solution and obtain a new unopened bottle to ensure the safety and effectiveness of wound care. Choices A, B, and C are incorrect because reusing an already opened and outdated solution or attempting to relabel it with a current date can compromise patient safety and increase the risk of infection.

5. An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement?

Correct answer: A

Rationale: Barbiturates cause central nervous system (CNS) depression, increasing the risk of falls. It is crucial for the nurse to assist the client to the bathroom to prevent potential injuries. Leaving the client alone may lead to accidents due to the effects of the medication. Monitoring and supporting the client during this activity is essential for ensuring safety and preventing falls.

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The healthcare provider is providing wound care to a client with a stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states 'clean the wound and then apply collagenase.' Collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the healthcare provider use to cleanse the pressure ulcer?
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