a client who is post op day 1 after abdominal surgery reports pain at the incision site the nurse notes the presence of a small amount of serosanguine
Logo

Nursing Elites

HESI RN

RN HESI Exit Exam

1. A client who is post-op day 1 after abdominal surgery reports pain at the incision site. The nurse notes the presence of a small amount of serosanguineous drainage. What is the most appropriate nursing action?

Correct answer: B

Rationale: The correct answer is to reinforce the dressing and document the findings. It is important to monitor the incision site closely after surgery, especially when there is a small amount of serosanguineous drainage. Reinforcing the dressing helps maintain cleanliness and pressure on the wound. Documenting the findings is crucial for tracking the client's progress and alerting healthcare providers if necessary. Applying a sterile dressing (Choice A) may not be needed if the current dressing is intact. Removing the dressing (Choice C) can increase the risk of contamination. Notifying the healthcare provider (Choice D) is not the first step for minor drainage on post-op day 1.

2. A client with a history of severe rheumatoid arthritis is receiving a corticosteroid. Which assessment finding should the nurse report to the healthcare provider immediately?

Correct answer: C

Rationale: Elevated blood pressure (140/90 mmHg) is a significant finding that the nurse should report immediately. Hypertension can be a severe side effect of corticosteroid therapy, especially in clients with preexisting conditions like rheumatoid arthritis. It requires prompt intervention to prevent complications such as cardiovascular events. The other options, while important to monitor, are not as critical as elevated blood pressure in this context. A blood glucose level of 180 mg/dL may indicate hyperglycemia, weight gain could be due to fluid retention, and increased joint pain is expected in a client with severe rheumatoid arthritis.

3. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which intervention should the nurse implement first?

Correct answer: A

Rationale: Administering intravenous insulin is the initial priority in managing diabetic ketoacidosis (DKA). Insulin helps to reduce blood glucose levels and correct metabolic acidosis, addressing the underlying cause of DKA. Monitoring urine output (choice B) is important but is not the first intervention needed. Administering intravenous fluids (choice C) is essential to correct dehydration in DKA, but insulin therapy takes precedence. Administering 50% dextrose IV push (choice D) is contraindicated in DKA as it can exacerbate hyperglycemia.

4. 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.

5. A client with cirrhosis is admitted with jaundice and ascites. Which intervention should the nurse implement first?

Correct answer: B

Rationale: Administering lactulose is the first priority in managing a client with cirrhosis to reduce ammonia levels and prevent worsening hepatic encephalopathy. Lactulose helps in decreasing the absorption of ammonia in the intestines and promotes its excretion through the stool. This intervention is crucial in preventing the development or progression of hepatic encephalopathy. Administering a diuretic (Choice A) may be necessary to manage ascites, but it is not the priority over lactulose in this scenario. Monitoring the client's weight (Choice C) is important to assess fluid retention but is not the first intervention required. Assessing the client's neurological status (Choice D) is essential in cirrhosis, but administering lactulose takes precedence to prevent hepatic encephalopathy.

Similar Questions

A male client with cancer who has lost 10 pounds during the last months tells the nurse that beef, chicken, and eggs, which used to be his favorite foods, now taste 'bitter'. He complains that he simply has no appetite. What action should the nurse implement?
A client with a history of atrial fibrillation is admitted with a new onset of confusion. Which intervention should the nurse implement first?
A client is admitted for type 2 diabetes mellitus (DM) and chronic kidney disease (CKD). Which breakfast selection by the client indicates effective learning?
A client with rheumatoid arthritis is prescribed methotrexate. Which assessment finding requires immediate intervention?
A client with gestational diabetes, at 39 weeks of gestation, is in the second stage of labor. After delivering the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first?

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