HESI

The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen, the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication? 1 Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care. 2 Develop a chart for the client, listing the times the medication should be taken. 3. Contact the primary healthcare provider and discuss the possibility of simplifying the medication regimen. 4 Instruct the client and client's children to put medications in a weekly pill organizer.

3. Contacting a medical care provider and discussing the possibility of simplifying the client's medication regimen will make it possible to use a weekly pill organizer : an empty pill box will remind the client who has a short-term memory deficit due to Alzheimer dementia that medication was taken and will prevent medication being taken multiple times.

To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse should change the administration set how often? 1 Every 4 to 8 hours 2 Every 12 to 24 hours 3 Every 24 to 48 hours 4. Every 72 to 96 hours

4. Best practice guidelines recommend replacing administration sets no more frequently than 72 to 96 hours after initiation of use in patients not receiving blood, blood products, or fat emulsions. This evidence-based practice is safe and cost effective.

Following a surgery on the neck, the client asks the nurse why the head of the bed is up so high. The nurse should tell the client that the high-Fowler position is preferred for what reason? 1 To avoid strain on the incision 2 To promote drainage of the wound 3 To provide stimulation for the client 4 To reduce edema at the operative site

4. This position prevents fluid accumulation in the tissue, thereby minimizing edema.

A registered nurse is teaching a nursing student about how to safely use a urinary catheter. Which statement made by the nursing student indicates ineffective learning? "I will avoid the pooling of urine in the tubing." 2 "I will avoid prolonged clamping of the tubing." Correct3 "I will avoid draining urine from the tubing before ambulation." 4 "I will avoid raising the drainage tube above the level of the bladder."

Correct3 "I will avoid draining urine from the tubing before ambulation. Urine should be drained [1] [2] from the tubing into the drainage container before ambulation or exercise. Pooling of the urine in the tubing should be avoided because this action may increase the risk of infection. Prolonged clamping of the tubing should be avoided because intermittent clamping helps to maintain the bladder's capacity and tone. The drainage tube should not be raised above the level of the bladder; urine should flow freely by way of gravity.

When assessing a client's blood pressure, the nurse notes that the blood pressure reading in the right arm is 10 mm Hg higher than the blood pressure reading in the left arm. The nurse understands what about this finding? 1 It is a normal occurrence. 2 It may indicate atherosclerosis. 3 It can be attributed to aortic disease. 4 It indicates lymphedema

1. When auscultating blood pressures, readings between the arms can vary as much as 10 mm Hg and are often higher in the right arm. Readings that differ by 15 mm Hg or more suggest atherosclerosis or disease of the aorta. Lymphedema is swelling in one or more extremities that is the result of impaired flow of the lymphatic system.

When suctioning a client with a tracheostomy, an important safety measure for the nurse is to do what? 1 Hyperventilate the client with room air before suctioning. 2 Apply suction only as the catheter is being withdrawn. 3 Insert the catheter until the cough reflex is stimulated. 4 Remove the inner cannula before inserting the suction catheter.

2. Apply suction only as the catheter is being withdrawn. Use of suction upon withdrawal of a suction catheter reduces unnecessary removal of oxygen. In addition, suction should be applied intermittently during the withdrawal procedure to prevent hypoxia. A sterile catheter is used to prevent infection and the catheter should only be inserted approximately 1 to 2 cm past the end of the tracheostomy tube to prevent tissue trauma. Hyperventilating a client before suctioning should always be with oxygen, not room air. Inserting the catheter until the cough reflex is stimulated frequently occurs and does help to mobilize secretions, but is not a safety measure. Removal of the inner cannula before inserting the suction catheter is not necessary.

The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may do what? 1 Force urine to back up into the kidneys. 2 Suppress production of urine. 3 Cause the device to pull away from the skin. 4 Tear the ileal conduit.

3. If the device becomes full and is not emptied, it may pull away from the skin and leak urine. Urine in contact with unprotected skin will irritate and cause skin breakdown.