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

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 receiving continuous ambulatory peritoneal dialysis (CAPD) has lost weight and exhibits increasing edema. What should the nurse prioritize?

Correct answer: A

Rationale: In a client receiving continuous ambulatory peritoneal dialysis (CAPD) who has lost weight and exhibits increasing edema, the nurse should prioritize evaluating the patency of the arteriovenous (AV) graft. This assessment is crucial to determine if hemodialysis can be resumed, addressing the client's presenting issues effectively. Instructing the client to continue a fluid-restricted diet (choice B) may not address the underlying issue related to the CAPD. Recommending support stockings for venous return (choice C) is not directly relevant to the situation described. Monitoring the client's serum albumin levels (choice D) may be important but does not directly address the immediate concern of weight loss and increasing edema in a CAPD client.

3. A client with hypertension has been prescribed a calcium channel blocker. What should the nurse include in the client's teaching plan?

Correct answer: A

Rationale: Corrected Rationale: Calcium channel blockers can cause bradycardia, so it is important for the client to monitor their heart rate regularly. This helps detect any significant changes in heart rate that may require medical attention. Choice B is incorrect because there is no need to avoid potassium-rich foods with calcium channel blockers. Choice C is incorrect as increasing fluid intake is not specifically related to calcium channel blockers. Choice D is incorrect as calcium channel blockers are usually taken with or without food, depending on the specific medication, but not specifically on an empty stomach.

4. The nurse is caring for a client who had a myocardial infarction 6 hours ago. The primary goal of care at this time is to

Correct answer: A

Rationale: The correct answer is A: 'Limit the effects of tissue damage.' After a myocardial infarction, the primary goal of care is to limit the damage to the heart muscle. This includes interventions to improve blood flow, oxygenation, and prevent further complications. Choice B ('Relieve pain and anxiety') is important but secondary to addressing tissue damage. Choice C ('Prevent arrhythmias') is also crucial but falls under the broader goal of limiting tissue damage. Choice D ('Reduce anxiety') is essential for holistic care but is not the primary goal immediately after a myocardial infarction.

5. A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated serum amylase. Which additional information is the client most likely to report to the nurse?

Correct answer: D

Rationale: The correct answer is D. In acute pancreatitis, abdominal pain typically worsens after eating due to the stimulation of the pancreas to release enzymes that irritate the inflamed tissues. Pain relief when lying supine is uncommon and usually exacerbates discomfort. While nausea and vomiting are common symptoms, they are not as indicative of changes in pain intensity. Pain radiating to the back is characteristic but does not specifically relate to exacerbation post-eating.

Similar Questions

A client with peripheral artery disease reports pain while walking. What intervention should the nurse recommend?
A client is receiving continuous intravenous heparin for a deep vein thrombosis. Which laboratory result should the nurse monitor to ensure therapeutic heparin levels?
A client has suspected compartment syndrome of the right lower leg. What is the nurse’s priority intervention?
A client is admitted with an epidural hematoma after a skateboarding accident. How should the nurse differentiate the vascular source of intracranial bleeding?
A client with diabetic ketoacidosis (DKA) is receiving an insulin infusion. Which finding indicates that the treatment is effective?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses