the nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy which finding would the nurse consider an indicat
Logo

Nursing Elites

HESI RN

HESI Medical Surgical Practice Exam Quizlet

1. The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding would the nurse consider an indication of progressive hepatic encephalopathy?

Correct answer: D

Rationale: Difficulty in handwriting is a common early sign of hepatic encephalopathy. Changes in handwriting can indicate progression or reversal of hepatic encephalopathy leading to coma. Choice (A) is a sign of ascites, not hepatic encephalopathy. Hypertension and a bounding pulse (Choice B) are not typically associated with hepatic encephalopathy. Decreased bowel sounds (Choice C) do not directly indicate an increase in serum ammonia level, which is the primary cause of hepatic encephalopathy.

2. Which of the following is a common complication of immobility?

Correct answer: B

Rationale: The correct answer is B, Pressure ulcers. Immobility can lead to pressure ulcers due to prolonged pressure on the skin, especially over bony prominences. Muscle hypertrophy (Choice A) is not a common complication of immobility; instead, muscle atrophy is more likely to occur due to disuse. Bone fractures (Choice C) can result from trauma but are not directly associated with immobility unless there is a fall or accident. Joint stiffness (Choice D) can develop due to lack of movement but is not as common or severe as pressure ulcers in cases of prolonged immobility.

3. A woman has been scheduled for a routine mammogram. What should the nurse tell the client?

Correct answer: D

Rationale: The correct answer is D. The nurse should instruct the client to avoid using deodorants, powders, or creams on the day of the mammogram. These products used in the axillary or breast area can interfere with the mammogram results and must be washed off before the test. Choices A, B, and C are incorrect because mammography typically takes less than 30 minutes, there is no need for fasting before the test, and some discomfort may be experienced during the procedure.

4. What is the most important nursing intervention for a patient with increased intracranial pressure (ICP)?

Correct answer: A

Rationale: Elevating the head of the bed to 30 degrees is crucial for a patient with increased intracranial pressure (ICP) because it helps promote venous drainage from the brain, thereby reducing ICP. Keeping the head of the bed elevated helps facilitate cerebral perfusion and can prevent a further increase in ICP. Administering diuretics (Choice B) may be considered in some cases to reduce fluid volume, but it is not the most critical intervention for immediate ICP management. Administering corticosteroids (Choice C) is not typically indicated for managing increased ICP unless there is a specific underlying condition requiring their use. Keeping the patient in a supine position (Choice D) can actually worsen ICP by impeding venous outflow from the brain, making it an incorrect choice for this scenario.

5. To reduce the risk of pulmonary complications for a client with ALS, which intervention should the nurse implement?

Correct answer: A

Rationale: Performing chest physiotherapy is the most appropriate intervention to reduce the risk of pulmonary complications in clients with ALS. Chest physiotherapy helps mobilize and clear respiratory secretions, improving lung function and reducing the risk of complications such as pneumonia. Teaching breathing exercises (Choice B) may be beneficial for some clients, but chest physiotherapy is more specifically targeted at managing pulmonary issues in ALS. Initiating passive range of motion exercises (Choice C) and establishing a regular bladder routine (Choice D) are important interventions in ALS care but are not directly related to reducing the risk of pulmonary complications.

Similar Questions

When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following?
What is an ideal goal of treatment set by the nurse in the care plan for a client diagnosed with chronic kidney disease (CKD) to reduce the risk of pulmonary edema?
The nurse assumes care for a patient who is currently receiving a dose of intravenous vancomycin (Vancocin) infusing at 20 mg/min. The nurse notes red blotches on the patient’s face, neck, and chest and assesses a blood pressure of 80/55 mm Hg. Which action will the nurse take?
A client has an elevated blood urea nitrogen (BUN)/creatinine ratio. Which action should the nurse take first?
The client is preparing a morning dose of insulin, which includes 10 units of regular and 22 units of NPH. The nurse is verifying the client's preparation accuracy. What should the syringe read for the correct dose?

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