a client is being prepared for surgery and has been placed on npo status which of the following is the nurses priority assessment
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Nursing Elites

HESI RN

HESI RN Exit Exam 2024 Quizlet Capstone

1. A client is being prepared for surgery and has been placed on NPO status. Which of the following is the nurse's priority assessment?

Correct answer: B

Rationale: The correct answer is B. Monitoring the client's compliance with NPO status is the priority assessment. Ensuring the client remains NPO (nothing by mouth) is crucial to reduce the risk of aspiration during surgery. Assessing the client's understanding of the procedure is important but not the priority at this moment. Checking vital signs is also essential but ensuring NPO status takes precedence for patient safety. Ensuring the client's consent form is signed is necessary but not the priority assessment compared to maintaining NPO status.

2. A client with a urinary tract infection is prescribed ciprofloxacin. What is the nurse's priority teaching?

Correct answer: A

Rationale: The correct answer is A: 'Take the medication with a full glass of water.' It is crucial for the nurse to teach the client to take ciprofloxacin with a full glass of water to prevent crystalluria, a potential side effect of the medication. Choice B is incorrect because ciprofloxacin does not require avoiding direct sunlight. Choice C is incorrect as taking the medication with meals is not necessary to prevent nausea. Choice D is incorrect as dizziness is not a common reason to discontinue ciprofloxacin.

3. A client with rheumatoid arthritis is prescribed methotrexate. What is the most important teaching point for the nurse to provide?

Correct answer: D

Rationale: The most important teaching point for a client prescribed methotrexate is to avoid direct sunlight to prevent photosensitivity. Methotrexate can make the skin more sensitive to sunlight, increasing the risk of sunburn and skin damage. Choices A, B, and C are important aspects of client care but are not specifically related to the side effect of photosensitivity caused by methotrexate.

4. Before administering digoxin to a client with heart failure, what is the most important assessment for the nurse to perform?

Correct answer: B

Rationale: The correct answer is to monitor the client's heart rate. Digoxin slows the heart rate, so it is crucial to assess the heart rate before administering the medication. If the heart rate is below 60 beats per minute, the dose should be held, and the healthcare provider should be notified. Checking the blood pressure (Choice A) is important but not as crucial as monitoring the heart rate in this case. Assessing the respiratory rate (Choice C) is not directly related to the action of digoxin. Reviewing the client's potassium level (Choice D) is important for clients taking digoxin due to the risk of hypokalemia, but assessing the heart rate takes priority.

5. The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the UAP?

Correct answer: D

Rationale: The UAP can be tasked with reporting complaints, monitoring weight gain, and tracking food and fluid intake, all of which are important in managing a client with Cushing's syndrome. These tasks fall within the UAP's scope of practice. Reporting client complaints helps in early identification of complications, monitoring weight is crucial due to fluid retention in Cushing's syndrome, and tracking food and fluid intake assists in dietary management. Choices A, B, and C are all necessary components of care for a client with Cushing's syndrome, making option D the correct answer.

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