the nurse is providing discharge instructions to a client who has had a stroke which intervention should the nurse recommend to prevent aspiration dur
Logo

Nursing Elites

HESI RN

HESI RN Exit Exam 2024 Quizlet Capstone

1. The nurse is providing discharge instructions to a client who has had a stroke. Which intervention should the nurse recommend to prevent aspiration during meals?

Correct answer: D

Rationale: Instructing the client to sit upright while eating is crucial to prevent aspiration in stroke clients. This position helps in safe swallowing and reduces the risk of food or liquid entering the airway. Encouraging the client to take large bites of food (Choice A) can increase the risk of choking and aspiration. Advising the client to eat quickly (Choice B) may lead to fatigue and compromise safe swallowing. Offering thin liquids (Choice C) can also increase the risk of aspiration in stroke clients, as thicker liquids are usually recommended to prevent aspiration.

2. A client with pneumonia is receiving oxygen therapy. What assessment finding requires immediate intervention?

Correct answer: B

Rationale: The correct answer is B. An oxygen saturation of 89% indicates hypoxemia, which is below the normal range (usually 95-100%). This finding requires immediate intervention as it signifies inadequate oxygenation. Options A, C, and D are within normal limits and do not indicate an urgent need for intervention. Option A indicates a good oxygen saturation level, option C denotes a normal respiratory rate, and option D suggests a normal heart rate. Therefore, these options do not require immediate intervention compared to the critically low oxygen saturation level of 89% in option B.

3. The nurse is preparing an older adult for discharge following cataract extraction. What is the most important instruction?

Correct answer: A

Rationale: The most important instruction for a patient following cataract extraction is to avoid straining, bending, or lifting heavy objects. These activities can increase intraocular pressure and potentially lead to complications such as bleeding or dislocation of the intraocular lens. Choices B, C, and D are not as critical in the immediate post-operative period. Limiting sunlight exposure and using direct lighting when reading are important but not as crucial as avoiding activities that can increase intraocular pressure. Irrigating the conjunctiva with saline before applying ointment is not a standard post-cataract surgery instruction.

4. A client with acute kidney injury (AKI) is experiencing hyperkalemia. What intervention should the nurse prioritize?

Correct answer: A

Rationale: The correct intervention for a client with acute kidney injury (AKI) experiencing hyperkalemia is to administer IV calcium gluconate. Calcium gluconate helps stabilize the myocardium and prevent life-threatening arrhythmias in hyperkalemia by antagonizing the cardiac effects of high potassium levels. Choice B, administering sodium polystyrene sulfonate (Kayexalate), is used to lower potassium levels in the gastrointestinal tract but is not the priority in acute severe hyperkalemia. Choice C, administering insulin with dextrose, helps drive potassium into cells but is not the priority in a client at risk for arrhythmias due to hyperkalemia. Choice D, restricting potassium intake in the client's diet, is a long-term strategy but is not the immediate priority in managing acute hyperkalemia.

5. A 78-year-old client with diabetes is being taught how to care for his feet. Which statement by the client indicates a need for further education?

Correct answer: A

Rationale: The correct answer is A. Soaking feet daily can lead to excessive moisture, which can increase the risk of skin breakdown or infection in diabetic clients. Choices B, C, and D are all correct statements for foot care in diabetic clients. Using a mirror for daily foot checks helps in early detection of any issues, applying lotion while avoiding the area between the toes helps keep the skin moisturized without creating a risk for fungal infections, and wearing properly fitting shoes is important to prevent pressure points and potential injuries.

Similar Questions

An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration status?
An unlicensed assistive personnel (UAP) reports a weak pulse of 44 beats per minute in a client. What action should the charge nurse implement?
The nurse is providing care for a client with heart failure who is prescribed furosemide. Which laboratory value should the nurse monitor closely?
In assessing a client with type 1 diabetes mellitus, the nurse notes that the client's respirations have changed from 16 breaths/min with a normal depth to 32 breaths/min and deep, and the client becomes lethargic. Which assessment data should the nurse obtain next?
An adult male is brought to the emergency department following a motorcycle accident, presenting with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse?

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