a client is admitted with a diagnosis of fluid volume excess which intervention should the nurse include in the clients plan of care
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Nursing Elites

HESI RN

HESI Fundamentals Practice Exam

1. A client is admitted with a diagnosis of fluid volume excess. Which intervention should the nurse include in the client's plan of care?

Correct answer: D

Rationale: Restricting dietary sodium intake (D) is the most critical intervention for a client with fluid volume excess to prevent further fluid retention. Encouraging increased fluid intake (A) would exacerbate the issue by adding more fluid to the body. Placing the client in a high Fowler's position (B) is more relevant for respiratory issues than fluid volume excess. While measuring intake and output (C) is important for assessing fluid balance, restricting sodium intake is the priority as it helps manage fluid levels more effectively by reducing fluid retention.

2. The healthcare provider who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the provider take?

Correct answer: C

Rationale: The correct action is for the provider not to administer the medication and to document the reason. In the case of a minor, parental consent is required for medical treatment, including medication administration. It is important to follow legal and ethical guidelines to ensure the adolescent's well-being and rights are protected. Choice A is incorrect because simply reviewing the chart does not address the lack of parental consent. Choice B is incorrect as obtaining parental consent should be done before medication administration. Choice D is incorrect as notifying the adolescent is not the appropriate action in this situation, as parental consent is legally required for a minor's medical treatment.

3. The client reports still being unable to sleep a week after learning progressive muscle relaxation techniques. Which action should the nurse take first?

Correct answer: D

Rationale: The nurse should first assess the client's adherence to the original instructions. By asking the client to describe the routine, the nurse can evaluate if the technique is being correctly implemented before considering further interventions. This choice is correct as it focuses on assessing the client's current practice. Option A is incorrect as adding regular exercise may not address the issue with the relaxation technique. Option B is incorrect as determining if the client has been keeping a sleep diary does not directly address the efficacy of the relaxation technique. Option C is incorrect as blindly encouraging the client to continue may not be the best approach without understanding how the technique is being practiced.

4. 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.

5. Which intervention is most important to include in the plan of care for a client at high risk for the development of postoperative thrombus formation?

Correct answer: D

Rationale: Thrombus formation is a risk for clients who are immobile postoperatively. Encouraging frequent ambulation helps to prevent stasis in the lower extremities, reducing the risk of thrombus formation. This intervention promotes circulation and prevents blood clot formation, making it the most important intervention in this situation.

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