a client is receiving a blood transfusion and reports feeling chilled and short of breath what is the nurses priority action
Logo

Nursing Elites

HESI RN

HESI RN Exit Exam Capstone

1. A client is receiving a blood transfusion and reports feeling chilled and short of breath. What is the nurse's priority action?

Correct answer: A

Rationale: The correct action for the nurse to take when a client receiving a blood transfusion reports feeling chilled and short of breath is to stop the transfusion immediately and notify the healthcare provider. These symptoms could indicate a transfusion reaction, which can be serious and even life-threatening. Stopping the transfusion is crucial to prevent further adverse reactions, and notifying the healthcare provider ensures timely intervention and appropriate management. Administering antihistamines, acetaminophen, or diphenhydramine is not the priority in this situation and may delay necessary actions to address the potential transfusion reaction.

2. A client is experiencing shortness of breath and wheezing. What is the nurse's first action?

Correct answer: A

Rationale: Administering a bronchodilator is the priority intervention to open the airways and relieve wheezing and shortness of breath. Bronchodilators work quickly to dilate the airways, making it easier for the client to breathe. Checking oxygen saturation is important but can be done after initiating bronchodilator therapy. Encouraging pursed-lip breathing and elevating the head of the bed can help improve breathing patterns but should follow the administration of the bronchodilator.

3. A client who had a vasectomy is in the post-recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?

Correct answer: A

Rationale: The most important point to reinforce after a vasectomy is to continue using contraception until the healthcare provider confirms the absence of sperm in the ejaculate. Choice A is correct because it emphasizes the necessity of another form of contraception until sperm absence is confirmed. Choice B is incorrect because it focuses on how a vasectomy works anatomically rather than the need for ongoing contraception. Choice C is incorrect as it discusses post-vasectomy care but does not address the need for continued contraception. Choice D is also incorrect as it refers to general post-procedure recommendations but does not highlight the crucial aspect of using contraception until sperm absence is confirmed.

4. A client with hypertension is prescribed a beta-blocker. What teaching should the nurse provide about this medication?

Correct answer: C

Rationale: The correct answer is to advise the client to rise slowly from a sitting or lying position. Beta-blockers can cause bradycardia and hypotension, so clients should be advised to rise slowly to prevent dizziness and falls. Monitoring the client's heart rate and blood pressure regularly is essential. Instructing the client to avoid high-potassium foods (Choice A) is not directly related to beta-blockers. While monitoring the client's heart rate (Choice B) is important, advising the client to rise slowly (Choice C) is more directly related to potential side effects of beta-blockers. Instructing the client to avoid sudden position changes (Choice D) is not as specific or essential as advising them to rise slowly to prevent adverse effects.

5. After administering a proton pump inhibitor, which action should the nurse take to evaluate the effectiveness of the medication?

Correct answer: B

Rationale: The correct answer is to ask the client about pain levels. Proton pump inhibitors (PPIs) work by reducing stomach acid to alleviate gastrointestinal pain. By inquiring about the client's pain experience, the nurse can directly assess the effectiveness of the medication. Monitoring bowel movements (Choice A) is not directly related to evaluating the effectiveness of a PPI. Checking vital signs (Choice C) may not reflect the medication's effectiveness in reducing stomach acid. Assessing for signs of bleeding (Choice D) is important but not the most direct way to evaluate the effectiveness of a PPI.

Similar Questions

A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the therapeutic response, which assessment should the nurse obtain?
A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement?
A client is admitted with a suspected pulmonary embolism (PE). What is the nurse's priority intervention?
The psychiatric nurse is caring for clients in an adolescent unit. Which client requires the nurse's immediate attention?
A client with chronic heart failure is admitted with worsening dyspnea. What is the nurse's priority action?

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