a client who has been on bed rest for several days is at risk for developing deep vein thrombosis dvt which intervention should the nurse include in t
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Nursing Elites

HESI RN

HESI Fundamentals Practice Test

1. A client who has been on bed rest for several days is at risk for developing deep vein thrombosis (DVT). Which intervention should the nurse include in the client's plan of care?

Correct answer: B

Rationale: Applying antiembolism stockings as prescribed (B) is an effective intervention to prevent deep vein thrombosis (DVT) in a client on bed rest. While encouraging ambulation (A), elevating the legs (C), and performing passive range-of-motion exercises (D) are also beneficial, compression stockings are particularly effective in reducing the risk of DVT by promoting venous return and reducing stasis in the lower extremities.

2. What assessment finding places a client at risk for problems associated with impaired skin integrity?

Correct answer: B

Rationale: The correct answer is B. A capillary refill time greater than 3 seconds indicates poor perfusion, leading to impaired skin integrity. Delayed capillary refill can compromise blood flow to the skin, increasing the risk of pressure ulcers or wounds due to reduced tissue perfusion. Choices A, C, and D are incorrect because scattered macules on the face, smooth nail texture, and presence of skin tenting are not direct indicators of impaired skin integrity or risk for skin problems.

3. While changing a client’s post-operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given a positive MRSA result, what is the most important action for the nurse to take?

Correct answer: C

Rationale: Initiating contact precautions is crucial in this situation to prevent the spread of MRSA infection. MRSA is a highly contagious bacterium that can spread through direct contact with an infected wound or by touching contaminated surfaces. By implementing contact precautions, the nurse can help contain the infection and protect other patients, healthcare workers, and visitors from being exposed to MRSA.

4. The healthcare provider is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery?

Correct answer: B

Rationale: Anticoagulants increase the risk of bleeding during surgery, which can lead to complications such as excessive bleeding and difficulty in achieving hemostasis. This poses a significant threat during a surgical procedure where controlling bleeding is crucial for a successful outcome. The other options (A, C, D) are not as critical as anticoagulants in terms of posing a threat for complications during surgery. Birth control pills, recently completing antibiotic therapy, and using laxatives do not directly impact bleeding risks during surgery compared to anticoagulants.

5. A healthcare professional is teaching a new colleague about the correct administration of subcutaneous (subQ) injections. Which instruction should the healthcare professional include?

Correct answer: C

Rationale: Pinching the skin before inserting the needle is essential in elevating the subcutaneous tissue away from the muscle. This technique ensures that the medication is administered into the correct tissue layer, promoting proper absorption and decreasing the risk of injecting into muscle tissue.

Similar Questions

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The client is receiving discharge teaching for a new diagnosis of asthma. Which statement by the client indicates a need for further teaching?
What instruction should be provided for a UAP caring for a client with MRSA who has an order for contact precautions?
The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first?

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