a client is recovering from a craniotomy and has a ventriculostomy in place the nurse notices the drainage from the ventriculostomy is suddenly increa
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HESI PN Exit Exam 2024 Quizlet

1. A client is recovering from a craniotomy and has a ventriculostomy in place. The nurse notices the drainage from the ventriculostomy is suddenly increasing. What should the nurse do first?

Correct answer: C

Rationale: A sudden increase in drainage from a ventriculostomy could indicate a serious complication such as increased intracranial pressure or hemorrhage. The priority action in this situation is to notify the healthcare provider immediately to ensure prompt evaluation and intervention. Increasing the head of the bed may be beneficial in some situations but is not the first action to take. Clamping the ventriculostomy tube is inappropriate as it can lead to increased intracranial pressure. Measuring the client's head circumference is not the priority when there is a sudden increase in ventriculostomy drainage.

2. At what age does a 9-year-old child typically lose which of the following teeth?

Correct answer: A

Rationale: A 9-year-old child typically loses their central incisors, not the lateral incisors or second molars. The central incisors are usually among the first teeth that children lose around 6 to 7 years of age, as part of the natural process of shedding primary teeth to make way for permanent teeth. The second molars and cuspids are typically lost later in the mixed dentition phase. Therefore, option A, 'Central incisor,' is the correct answer.

3. A 12-year-old child is receiving a blood transfusion via an infusion pump and begins to complain of 'itchy' skin 15 minutes after the unit of blood is started. The child appears flushed. What action should the nurse take first?

Correct answer: B

Rationale: Stopping the transfusion immediately is crucial when signs of a transfusion reaction, such as itching and flushing, occur. This action is taken to prevent further exposure to the potentially harmful transfused blood. Applying lotion to the skin, inspecting the infusion site, or obtaining vital signs can be important but are secondary to stopping the transfusion to ensure the safety of the child. Applying lotion may not address the underlying issue of a possible transfusion reaction. Inspecting the infusion site and obtaining vital signs can be done after stopping the transfusion, as patient safety is the top priority in this situation.

4. Which of the following is NOT a second-line agent used for the treatment of Tuberculosis?

Correct answer: C

Rationale: The correct answer is C, Rifabutin. Rifabutin is actually a first-line drug used in the treatment of tuberculosis. Choices A, B, and D (Amikacin, Moxifloxacin, and Cycloserine) are considered second-line agents for tuberculosis treatment. These drugs are used when the first-line medications are either ineffective or cannot be tolerated by the patient.

5. A client who had an abdominal hysterectomy is experiencing minimal urine output despite adequate fluid intake. What should the nurse assess first?

Correct answer: C

Rationale: Assessing the patency of the urinary catheter is crucial in this situation. A blocked catheter could be a common cause of decreased urine output following surgery. While checking the IV catheter insertion site (Choice B) is important, it is not the priority in this case. Examining the client's bladder for distension (Choice A) is relevant, but assessing the patency of the catheter takes precedence in resolving the issue of decreased urine output. Monitoring vital signs (Choice D) is a routine nursing task but not the priority when dealing with decreased urine output post-surgery.

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