a client is receiving continuous bladder irrigation via a triple lumen suprapubic catheter that was placed during prostatectomy which report by the un
Logo

Nursing Elites

HESI RN

HESI 799 RN Exit Exam

1. A client is receiving continuous bladder irrigation via a triple-lumen suprapubic catheter that was placed during a prostatectomy. Which report by the unlicensed assistive personnel (UAP) requires intervention by the nurse?

Correct answer: A

Rationale: The correct answer is A. Leakage around the catheter insertion site may indicate a problem with the catheter placement or function, requiring immediate intervention. Pink-tinged urine in the drainage bag is expected due to the continuous bladder irrigation. Discomfort at the catheter site is common after the procedure. Decreased urine output in the last hour may be due to the continuous bladder irrigation and doesn't require immediate intervention.

2. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which clinical finding requires immediate intervention?

Correct answer: C

Rationale: The correct answer is C: Use of accessory muscles. In a client with COPD receiving supplemental oxygen, the use of accessory muscles is a critical finding that requires immediate intervention. This observation indicates increased work of breathing, suggesting respiratory distress. Addressing this issue promptly is crucial to prevent further respiratory compromise. Choice A, oxygen saturation of 90%, is slightly below the normal range but may not require immediate intervention unless it continues to decrease. Choice B, a respiratory rate of 24 breaths per minute, is within normal limits for an adult and does not indicate an urgent issue. Choice D, inspiratory crackles, may be present in COPD due to secretions or inflammation but do not necessitate immediate intervention unless associated with other concerning signs.

3. When assessing a client with left-sided heart failure, which intervention should the nurse implement first?

Correct answer: A

Rationale: Administering oxygen therapy is the initial intervention for a client with left-sided heart failure. This action is crucial in improving oxygen levels and reducing pulmonary congestion. Monitoring urine output is important for assessing renal function in heart failure, but it is not the priority over ensuring adequate oxygenation. Administering loop diuretics helps manage fluid overload but should come after addressing oxygen needs. Morphine may be indicated for pain or anxiety in some cases, but it is not the primary intervention for left-sided heart failure.

4. A client with chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which intervention should the nurse implement first?

Correct answer: A

Rationale: In a client with COPD admitted with pneumonia, the priority intervention should be to administer oxygen therapy as prescribed. This is crucial to improve oxygenation, especially in a client with compromised respiratory function. Elevating the head of the bed can help with breathing but is secondary to ensuring adequate oxygenation. Obtaining a sputum culture and administering antibiotics are important steps in the treatment of pneumonia but come after ensuring adequate oxygen supply.

5. A client with a history of alcoholism is admitted with confusion, ataxia, and nystagmus. Which nursing intervention is a priority for this client?

Correct answer: B

Rationale: The correct answer is B: Administer thiamine as prescribed. Administering thiamine is crucial in clients with a history of alcoholism to prevent Wernicke's encephalopathy, which is characterized by confusion, ataxia, and nystagmus. Monitoring for signs of alcohol withdrawal (choice A) is important but not the priority. Providing a quiet environment (choice C) and initiating fall precautions (choice D) are important interventions, but administering thiamine takes precedence due to the risk of Wernicke's encephalopathy.

Similar Questions

A client with chronic renal failure (CRF) is placed on a protein-restricted diet. Which nutritional goal supports this dietary change?
A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which assessment finding should be reported to the healthcare provider immediately?
An elderly female client with osteoarthritis reports increasing pain and stiffness in her right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of her symptoms?
A client's subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next?
A client with a nasogastric tube in place following gastric surgery reports nausea. What is the most appropriate nursing 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