a client requires application of an eye shield to the right eye what should the nurse do in order to apply tape in which direction to anchor the shiel
Logo

Nursing Elites

HESI LPN

Adult Health 1 Exam 1

1. A client requires application of an eye shield to the right eye. What should the nurse do in order to apply tape to anchor the shield most effectively?

Correct answer: C

Rationale: The correct way to apply tape to anchor an eye shield effectively is to attach the tape from the lower eyelid to the upper forehead. This method provides stability for the shield without putting pressure on the eye itself, thus helping to protect the eye. Choices A, B, and D are incorrect because taping from the cheek to the forehead, securing tape from the nose to the ear, or using circular bandaging around the head may not provide the necessary stability and protection required for the eye shield.

2. A client with a history of chronic heart failure is admitted with symptoms of dyspnea and fatigue. What initial intervention should the nurse prepare to implement?

Correct answer: B

Rationale: The correct initial intervention for a client with chronic heart failure presenting with dyspnea and fatigue is oxygen therapy. Oxygen therapy can help relieve dyspnea and improve oxygen saturation levels, which are crucial in managing heart failure exacerbations. Administering IV diuretics may be necessary later to address fluid overload, but oxygen therapy takes precedence in addressing the immediate respiratory distress. Bed rest and dietary consultation are important aspects of care for heart failure patients, but in this scenario, oxygen therapy is the priority to improve the client's respiratory status.

3. 4 hours after administration of 20U of regular insulin, the client becomes shaky and diaphoretic. What action should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take when a client becomes shaky and diaphoretic after insulin administration, indicating hypoglycemia, is to provide the client with carbohydrates like crackers and milk. Carbohydrates help raise blood glucose levels quickly. Encouraging the client to eat crackers and milk (Choice A) is the appropriate immediate action to address the hypoglycemia. Administering more insulin (Choice B) would worsen hypoglycemia, and recording the reaction (Choice D) is important but not the immediate action needed to treat the hypoglycemia.

4. What should the nurse prioritize when providing discharge instructions to a client with a new colostomy?

Correct answer: A

Rationale: Correct answer: Skin care around the stoma site. Proper skin care around the stoma site is crucial for preventing skin irritation and infection, which are common issues for patients with new colostomies. While the schedule for colostomy bag replacement (Option B) is important, it is not the priority during initial discharge instructions. Techniques for odor control (Option C) are relevant but secondary to skin care for a new colostomy. Dietary modifications (Option D) may be discussed later but are not the priority at this stage.

5. When reconstituted, how many milligrams are in each milliliter of solution?

Correct answer: D

Rationale: After reconstitution, the concentration of the cefazolin solution is 400 mg/mL. This calculation is derived by dividing the total milligrams in the vial (1000 mg) by the total volume after reconstitution (2.5 mL). Therefore, each milliliter of the solution contains 400 mg of cefazolin. Choices A, B, and C are incorrect as they do not match the correct calculation based on the information provided.

Similar Questions

A client with a history of hypertension is admitted to the hospital for a suspected myocardial infarction. Which of the following is the priority nursing action?
What action should the nurse implement in caring for a client following an electroencephalogram (EEG)?
When inserting an indwelling urinary catheter in a female client and urine flows into the tubing, what is the next action?
What is the primary purpose of a chest tube in a client's care?
A client is admitted to the hospital with a diagnosis of Pneumonia. Which intervention should the nurse implement to prevent complications associated with Pneumonia?

Access More Features

HESI LPN Basic
$69.99/ 30 days

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

HESI LPN Premium
$149.99/ 90 days

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

Other Courses