a client with rheumatoid arthritis reports a new onset of increasing fatigue what intervention should the nurse implement first
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Nursing Elites

HESI LPN

HESI CAT Exam

1. A client with rheumatoid arthritis reports a new onset of increasing fatigue. What intervention should the nurse implement first?

Correct answer: C

Rationale: The correct first intervention for a client with rheumatoid arthritis reporting increasing fatigue is to assess the client for pallor. Fatigue can be a sign of anemia or other complications; assessing for pallor can help determine if anemia is the cause. Option A is incorrect as it does not address the underlying cause of fatigue. Option B assumes the cause without further assessment. Option D is important for overall health but assessing for pallor takes precedence to identify immediate issues related to fatigue.

2. Which intervention should the nurse include in the plan of care for a patient with tetanus?

Correct answer: C

Rationale: The correct intervention for a patient with tetanus is to minimize the amount of stimuli in the room. Tetanus can lead to muscle spasms and heightened sensitivity to stimuli, making it essential to reduce environmental triggers for the patient's comfort and safety. Opening window shades for natural light (Choice A) may exacerbate sensitivity to light and worsen symptoms. Encouraging coughing and deep breathing (Choice B) is not directly related to managing tetanus symptoms. While repositioning the patient every hour (Choice D) is important for preventing pressure ulcers, it is not the priority when managing tetanus, which requires a quiet, low-stimulus environment to minimize muscle spasms and discomfort.

3. A male client admitted three days ago with respiratory failure is intubated and receiving 40% oxygen per facemask. Currently, his temperature is 99°F, capillary refill is less than 4 seconds, and respiratory effort is within normal limits. What outcome should the nurse evaluate to measure for successful extubation?

Correct answer: D

Rationale: Successful extubation is primarily measured by the client's ability to maintain an effective breathing pattern. This indicates that the client can adequately oxygenate and ventilate without the need for artificial airway support. Choices A, B, and C are important aspects of patient care but are not the primary outcomes to evaluate for successful extubation. Adequate tissue perfusion, freedom from injury, and prevention of infection are ongoing goals during the client's hospitalization but are not the immediate focus when considering extubation.

4. The nurse is assessing a client with pulmonary edema who is reporting two-pillow orthopnea and paroxysmal nocturnal dyspnea. The nurse identifies rapid shallow respirations and the use of accessory muscles. Which action should the nurse include in the client’s plan of care?

Correct answer: A

Rationale: Administering amiodarone is appropriate if arrhythmias are present in the context of pulmonary edema, as it helps manage irregular heart rhythms. In this case, the client is experiencing symptoms related to respiratory distress, and amiodarone can address potential arrhythmias contributing to the condition. Options B and D are not directly related to managing symptoms of pulmonary edema and do not address the underlying cause of the client's distress. Option C, performing blood tests for cardiac enzymes, is important for assessing possible myocardial damage but does not directly address the immediate respiratory distress associated with pulmonary edema.

5. Based on the information provided in this client’s medical record during labor, which intervention should the nurse implement?

Correct answer: C

Rationale: Turning the client to the right lateral position is essential as it can improve fetal oxygenation and uterine blood flow, promoting better labor outcomes. This intervention helps relieve pressure on blood vessels, enhancing blood flow to the placenta and improving oxygen supply to the fetus. Applying oxygen at a specific rate may not address the underlying issue of compromised blood flow and oxygenation. Stopping the oxytocin infusion is not the priority unless medically indicated as it can affect labor progression. While monitoring the progress of labor is important, actively addressing the compromised fetal oxygenation and uterine blood flow by changing the client's position takes precedence in this scenario.

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