the nurse is assessing a client who has just received anesthesia what is the most critical finding to report to the physician
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Nursing Elites

HESI RN

HESI RN Exit Exam 2023 Capstone

1. The healthcare provider is assessing a client who has just received anesthesia. What is the most critical finding to report to the healthcare provider?

Correct answer: B

Rationale: A significant drop in blood pressure following anesthesia could indicate a serious reaction, such as hypovolemia or anesthetic-induced hypotension. This requires immediate medical attention, while other symptoms like dizziness, mild nausea, and dry mouth are more common and less critical. Dizziness could be expected due to the effects of anesthesia, mild nausea is a common side effect, and dry mouth is a known effect of anesthesia as well.

2. A nurse receives a report on a client who is four hours post-total abdominal hysterectomy. The previous nurse reported that it was necessary to change the client's perineal pad hourly and that it is again saturated. The previous nurse also reports that the client's urinary output has decreased. Which action should the nurse implement first?

Correct answer: D

Rationale: Saturation of the perineal pad after a hysterectomy suggests excessive vaginal bleeding, which must be addressed immediately. Assessing for vaginal bleeding is the priority in this situation as it can lead to hypovolemic shock. Measuring urinary output, assessing for weakness or dizziness, and increasing IV fluids are important interventions but checking for vaginal bleeding takes precedence due to the risk of hemorrhage post-hysterectomy.

3. A male client with HIV on saquinavir and other antiretrovirals reports increased hunger and thirst but weight loss. Which action should the nurse take?

Correct answer: A

Rationale: Increased thirst and hunger while losing weight may indicate hyperglycemia, a common side effect of saquinavir and other antiretrovirals. Using a glucometer to assess capillary glucose levels is essential to evaluate for hyperglycemia. Choice B is incorrect because increasing the dose of medication without assessing blood glucose levels can be dangerous. Choice C is incorrect because weight loss may not necessarily improve with viral load reduction and doesn't address the immediate concern of hyperglycemia. Choice D is irrelevant to the presenting symptoms and should not be a priority over assessing for hyperglycemia.

4. Which dietary instruction is most important for a client with renal disease?

Correct answer: B

Rationale: The most important dietary instruction for a client with renal disease is to limit fluid intake to 1500 ml/day. This is essential to prevent fluid overload, manage electrolyte balance, and reduce strain on the kidneys. Choice A is incorrect because while protein restriction may be necessary in some cases, avoiding all protein-rich foods is not recommended as some protein intake is essential for overall health. Choice C is incorrect because increasing potassium intake is generally not advised for clients with renal disease, as they often need to limit potassium intake. Choice D is also incorrect because while consuming small, frequent meals may be helpful, emphasizing a diet high in carbohydrates is not typically the primary focus for clients with renal disease.

5. The client provides three positive responses to the CAGE questionnaire. Which interpretation should the nurse provide?

Correct answer: B

Rationale: The CAGE questionnaire is a widely used screening tool for alcohol dependence. Two or more positive responses suggest a higher likelihood of alcohol dependence. One positive response may indicate potential alcohol issues, but two or more significantly increase the likelihood of dependence. Therefore, choice B is the most appropriate interpretation. Choice A is incorrect because the CAGE questionnaire specifically focuses on alcohol-related issues, not substance abuse in general. Choice C is incorrect as one positive response does not indicate addiction but rather raises a concern. Choice D is incorrect as not all responses need to be positive to suggest alcohol dependence.

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