a client with a small bowel obstruction is experiencing frequent vomiting which instructions are most important for the nurse to provide to the unlice
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Nursing Elites

HESI RN

HESI RN CAT Exit Exam 1

1. A client with a small bowel obstruction is experiencing frequent vomiting. Which instructions are most important for the nurse to provide to the unlicensed assistive personnel (UAP) who is completing morning care for this client?

Correct answer: D

Rationale: The correct answer is D, 'Measure all emesis accurately.' When a client with a small bowel obstruction is experiencing frequent vomiting, measuring emesis accurately is crucial for monitoring fluid balance and preventing dehydration. Choice A, 'Maintain a quiet environment,' while important for patient comfort, is not as critical as accurately measuring emesis. Choices B and C, 'Ensure the linens are clean and dry' and 'Place an air deodorizer in the room,' focus on environmental factors that, although helpful, are not as essential as monitoring the client's fluid balance in this situation.

2. A client diagnosed with a deep vein thrombus (DVT) followed by a diagnosis of pulmonary embolism (PE) is receiving heparin via an infusion pump at a rate of 1400 u/hour. The client tells the nurse, 'I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home'. What response is best for the nurse to provide?

Correct answer: A

Rationale: Choice A is the best response because it educates the client about the role of heparin in preventing future clot formation rather than dissolving the existing clot. This helps the client understand the medication's function and the importance of closely monitoring for signs of bleeding, a common side effect of heparin therapy. Choice B acknowledges the client's concern but does not provide accurate information about heparin's mechanism of action. Choice C is premature as it suggests transitioning to home therapy without addressing the client's concerns or explaining heparin's purpose. Choice D does not address the client's statement and instead questions their desire to leave the hospital.

3. A client with an electrical burn on the forearm asks the nurse why there is no feeling of pain from the burn. During the dressing change, the nurse determines that the burn is dry, waxy, and white. What information should the nurse provide this client?

Correct answer: C

Rationale: The correct answer is C: 'The full thickness burn has destroyed the nerves.' In full thickness burns, also known as third-degree burns, the nerve endings are destroyed, leading to a lack of pain sensation at the site of the burn. The description of the burn as dry, waxy, and white indicates a full thickness burn. Choices A, B, and D are incorrect because they do not explain the absence of pain in full thickness burns. Choice A is incorrect as a full-thickness burn involves significant tissue destruction. Choice B is incorrect because nerve compression would not explain the lack of pain in this context. Choice D is incorrect because second-degree burns, unlike full-thickness burns, are painful due to nerve endings being intact.

4. Which assessment finding is most indicative of deep vein thrombosis (DVT) in a client's right leg?

Correct answer: C

Rationale: The correct answer is C because a significant increase in the circumference of the right calf compared to the left calf is a classic sign of deep vein thrombosis (DVT). Option A is incorrect as dorsiflexing the right foot and left on command does not specifically indicate DVT. Option B describes an ecchymosis area which is more indicative of a bruise rather than DVT. Option D suggests bilateral lower extremity edema, which is not specific to DVT and can be seen in various conditions such as heart failure or renal issues.

5. A client who is 32-weeks pregnant is diagnosed with partial placenta previa. Which instruction should the nurse include in this client’s teaching plan?

Correct answer: C

Rationale: Refraining from sexual intercourse helps prevent complications with partial placenta previa.

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