a client taking clopidogrel reports the onset of diarrhea which nursing action should the nurse implement first
Logo

Nursing Elites

HESI LPN

HESI CAT Exam Quizlet

1. A client taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement first?

Correct answer: A

Rationale: Observing the stool’s appearance should be implemented first as it helps determine the nature and possible severity of the diarrhea, which is essential in managing the side effect. Assessing skin turgor (Choice B) is not the priority in this situation. Reviewing laboratory values (Choice C) can provide additional information but is not the initial step. Auscultating bowel sounds (Choice D) is not the priority when the client is experiencing diarrhea.

2. What is the best response when a two-year-old boy begins to cry when his mother starts to leave?

Correct answer: B

Rationale: The best response in this situation is to offer a distraction to the child. Reading a book can help soothe the child during separation from the parent by redirecting their attention. Choice A might not be as effective as providing a distraction like reading a book. Choice C dismisses the child's feelings and generalizes behavior, which is not helpful. Choice D diminishes the child's emotions and does not provide a constructive way to help the child cope with the separation anxiety.

3. An adult male is admitted to the intensive care unit because he experienced a sudden onset of sharp chest pain and shortness of breath earlier today. Following an emergent pulmonary angiogram, the client is diagnosed with a pulmonary embolism. Which intervention is most important for the nurse to include in this client’s plan of care?

Correct answer: A

Rationale: In a patient diagnosed with a pulmonary embolism, the most critical intervention is to monitor for signs of increased bleeding. Pulmonary embolism treatment often involves anticoagulation therapy, which increases the risk of bleeding. Monitoring for signs of bleeding such as bruising, petechiae, hematuria, or gastrointestinal bleeding is essential to prevent complications. Instructing on the use of incentive spirometry can be beneficial for preventing pulmonary complications but is not as urgent as monitoring for bleeding. Observing for confusion and restlessness may indicate hypoxia but is not the most crucial intervention in this scenario. Administering intravenous opioids for severe pain might be necessary but is not the priority compared to monitoring for bleeding, which is directly related to the treatment for pulmonary embolism.

4. After removing an IV that became infiltrated in the client’s left forearm, which site should the nurse select as a possible site to insert another IV catheter?

Correct answer: A

Rationale: The correct answer is A: Right hand. When an IV becomes infiltrated in the client's left forearm, it is essential to avoid the same side due to the risk of complications. Therefore, the right hand is a suitable alternative site for IV insertion. Choices B, C, and D are incorrect. Choosing the right forearm (B) would still be on the same side, which increases the risk of complications. The left hand (C) is not a preferred option immediately after an infiltration in the left forearm. The right subclavian (D) is an invasive site typically reserved for central line placement and not a first-line choice for IV insertion.

5. The unlicensed assistive personnel (UAP) reports that a client’s blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. What action should the nurse implement?

Correct answer: D

Rationale: When a client cannot have their blood pressure measured due to specific circumstances such as casts on both arms, the nurse should document the reason why the blood pressure cannot be obtained accurately. This documentation is crucial for maintaining a clear record of the client's condition and for continuity of care. Advising the UAP to document the last blood pressure obtained (Choice A) does not address the current inability to measure the blood pressure. Estimating the blood pressure by assessing the pulse volume of radial pulses (Choice B) is not a reliable method for obtaining accurate blood pressure readings. Demonstrating how to palpate the popliteal pulse (Choice C) is irrelevant in this situation as it does not provide a solution for accurately measuring the blood pressure.

Similar Questions

A client with a prescription for “do not resuscitate” (DNR) begins to manifest signs of impending death. After notifying the family of the client’s status, what priority action should the nurse implement?
The nurse receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?
A nurse working on an endocrine unit should see which client first?
An adult suffered burns to the face and chest resulting from a grease fire. On admission, the client was intubated, and a 2-liter bolus of normal saline was administered IV. Currently, the normal saline is infusing at 250 ml/hour. The client’s heart rate is 120 beats/minute, blood pressure is 90/50 mmHg, respirations are 12 breaths/minute over the ventilated 12 breaths for a total of 24 breaths/minute, and the central venous pressure (CVP) is 4 mm H2O. Which intervention should the nurse implement?
A client with a history of myocardial infarction (MI) is receiving a beta-blocker medication. What is the most important outcome for the nurse to monitor?

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