the nurse is caring for a client who just underwent a coronary artery bypass graft what is the priority nursing action during the immediate postoperat
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Nursing Elites

HESI LPN

Adult Health 1 Final Exam

1. What is the priority nursing action during the immediate postoperative period for a client who just underwent a coronary artery bypass graft?

Correct answer: D

Rationale: Maintaining a patent airway is the priority nursing action during the immediate postoperative period for a client who just underwent a coronary artery bypass graft. This is crucial to ensure adequate oxygenation, especially in the early recovery phase. Monitoring for signs of infection, ensuring the client is pain-free, and assessing for bleeding and arrhythmias are important aspects of postoperative care but maintaining a clear airway takes precedence in this scenario to prevent hypoxia and respiratory compromise. In the immediate postoperative period, maintaining a patent airway is essential to prevent complications such as airway obstruction, hypoxia, and respiratory distress, which are critical in ensuring the client's safety and recovery.

2. The nurse is caring for a client with a diagnosis of major depressive disorder who has been prescribed fluoxetine (Prozac). What is the most important teaching point?

Correct answer: B

Rationale: The correct teaching point is to instruct the client to report any increase in suicidal thoughts. This is crucial because SSRIs like fluoxetine can initially increase suicidal ideation, especially at the beginning of treatment. Choice A is corrected to emphasize that fluoxetine can be taken with or without food. Choice C is unrelated as it pertains more to MAOIs than SSRIs like fluoxetine. Choice D is inaccurate as antidepressants like fluoxetine may take weeks to show significant improvement in symptoms, not within 24 hours.

3. The client with a diagnosis of hypertension is being taught about lifestyle changes. Which recommendation is most important to include?

Correct answer: B

Rationale: Engaging in regular physical activity is crucial for individuals with hypertension as it helps lower blood pressure and improve cardiovascular health. Physical activity is known to have a significant impact on reducing hypertension and overall cardiovascular risk. Choice A, increasing sodium intake, is incorrect as reducing sodium is typically recommended for hypertension to help lower blood pressure. Choice C, avoiding foods high in fat, is beneficial for overall health but not the most crucial recommendation for hypertension management. Choice D, limiting fluid intake to 1 liter per day, is not a standard recommendation for hypertension unless advised by a healthcare provider for specific cases. Therefore, the most important recommendation for the client with hypertension is to engage in regular physical activity.

4. The client with hypertension is being taught about lifestyle changes. Which recommendation is most important to include?

Correct answer: B

Rationale: Engaging in regular physical activity is crucial for managing hypertension as it helps lower blood pressure. Regular exercise can improve heart health, increase circulation, and contribute to overall well-being, all of which are beneficial for individuals with hypertension. Choice A, increasing sodium intake, is incorrect as reducing sodium is recommended for hypertension to help lower blood pressure. Choice C, consuming a diet high in saturated fats, is incorrect as a diet high in saturated fats can negatively impact blood pressure and cardiovascular health. Choice D, limiting fluid intake, is incorrect as maintaining adequate hydration is important for overall health and not directly related to hypertension management.

5. What is the most important information the nurse should teach a diabetic client about foot care?

Correct answer: A

Rationale: The correct answer is to inspect feet daily. For diabetic clients, daily foot inspection is crucial in preventing complications like infections and ulcers. By checking their feet regularly, clients can identify any issues early and seek appropriate medical care. The other choices are important aspects of foot care for diabetic clients but not as critical as daily foot inspections. Wearing cotton socks helps in moisture control, using lukewarm water to wash feet helps prevent skin damage, and cutting nails straight across prevents ingrown nails. However, daily foot inspection is the most vital as it allows for early detection of any potential problems, which is key in diabetic foot care.

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