a client who recently had a hip replacement has a strong odor from the urine and bloody drainage on the surgical dressing what should the nurse do fir
Logo

Nursing Elites

HESI RN

HESI RN Exit Exam 2024 Capstone

1. A client who recently had a hip replacement has a strong odor from the urine and bloody drainage on the surgical dressing. What should the nurse do first?

Correct answer: C

Rationale: The correct answer is to measure the client's oral temperature. In this scenario, the strong odor from urine and bloody drainage on the surgical dressing are concerning signs that suggest a possible infection. Fever is a common sign of infection, so measuring the client's temperature will help confirm if an infection is present. Obtaining a urine sample, inserting an indwelling urinary catheter, or removing the dressing and assessing the surgical site are not the first priority actions when infection is suspected. These actions may be necessary later but assessing the client's temperature is the initial step to evaluate for infection.

2. An adolescent client with intellectual disability refuses oral hygiene. A behavior modification program is recommended. Which reinforcement is best for the nurse to implement?

Correct answer: D

Rationale: In this scenario, the best reinforcement for the nurse to implement is preferred activities or privileges for compliance. Positive reinforcement with privileges is effective in encouraging behavior change in adolescents, including those with intellectual disabilities. Choice A (Candy for successful oral hygiene tasks) may not be suitable as it involves providing a sugary reward, which contradicts the goal of oral hygiene. Choice B (Tokens for each successful oral hygiene task) could be effective but may not be as motivating as preferred activities or privileges. Choice C (Privilege restrictions for refusing oral hygiene tasks) focuses on negative reinforcement, which is not as effective as positive reinforcement in behavior modification.

3. A client is scheduled for a spiral CT scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow-up by the nurse?

Correct answer: A

Rationale: An allergy to shellfish often indicates an allergy to iodine, which is used in contrast dyes for CT scans. This poses a significant risk of an allergic reaction during the procedure. The nurse must ensure appropriate precautions or alternative imaging are considered. Choices B, C, and D are not directly contraindicated for a CT scan with contrast. Smoking history, metformin use, and controlled hypertension do not typically impact the safety or feasibility of the procedure.

4. A client with diabetes mellitus is experiencing hyperglycemia. What laboratory value should the nurse monitor to evaluate long-term glucose control?

Correct answer: B

Rationale: The correct answer is B: Glycosylated hemoglobin (A1C). Glycosylated hemoglobin reflects long-term glucose control over the past three months. Monitoring blood glucose levels provides information on the current glucose status and immediate control, but it does not give a comprehensive view of long-term control. Urine output and serum ketone levels are important indicators for other aspects of diabetes management, such as hydration status and ketone production during hyperglycemic episodes, but they do not directly reflect long-term glucose control.

5. The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective?

Correct answer: B

Rationale: Phenytoin can cause gingival hyperplasia, so good oral hygiene is important to prevent complications.

Similar Questions

A client with gastroesophageal reflux disease (GERD) reports frequent heartburn. What dietary modification should the nurse recommend?
To auscultate for a carotid bruit, where should the nurse place the stethoscope?
A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. Which action should the nurse take?
An older client with chronic emphysema is admitted to the emergency room with acute weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview?
The nurse is teaching a client about postoperative care following a total knee arthroplasty. What instruction should the nurse prioritize?

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