when caring for a client in hemorrhagic shock how should the nurse position the client
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Nursing Elites

HESI RN

HESI Quizlet Fundamentals

1. When caring for a client in hemorrhagic shock, how should the nurse position the client?

Correct answer: A

Rationale: When caring for a client in hemorrhagic shock, the nurse should position the client flat in bed with legs elevated. Elevating the legs helps increase venous return to the heart, aiding in the management of hemorrhagic shock by maintaining perfusion to vital organs.

2. Which client care task requires the nurse to wear barrier gloves as mandated by the Standard Precautions protocol?

Correct answer: D

Rationale: The correct answer is D because emptying a urinary catheter drainage bag exposes the nurse to body fluids, necessitating the use of barrier gloves as per Standard Precautions to prevent potential infection transmission.

3. The healthcare provider is assessing a client with a diagnosis of pneumonia. Which assessment finding is most concerning?

Correct answer: D

Rationale: A respiratory rate of 28 breaths per minute (D) is most concerning because it indicates respiratory distress and requires immediate intervention. While coarse crackles (A), fever (B), and productive cough (C) are common findings in pneumonia, a high respiratory rate signifies a more severe condition that needs prompt attention to prevent respiratory failure. Monitoring the respiratory rate is crucial in assessing the severity of respiratory distress in pneumonia, as it can rapidly progress to respiratory failure if not managed promptly.

4. The healthcare professional is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. What action should the healthcare professional take next?

Correct answer: A

Rationale: The client's response to a painful stimulus indicates a purposeful reaction, which should be accurately documented as per the assessment findings. This documentation is essential for ongoing monitoring and communication of the client's condition to the healthcare team.

5. When turning an immobile bedridden client without assistance, which action best ensures client safety?

Correct answer: B

Rationale: The correct answer is to put bed rails up on the side of the bed opposite from the nurse. This action is essential to prevent the client from falling out of bed during the turning process. Since the nurse can only stand on one side of the bed, having the bed rails up on the opposite side provides an additional safety measure. Securing the client's arm and leg or lowering the head of the bed would not prevent the client from falling and may pose a risk of injury. Using a turn sheet correctly can be helpful, but ensuring the bed rails are up is a more direct safety measure in this situation.

Similar Questions

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The healthcare provider obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the healthcare provider implement first?
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