HESI Reduce Risk Potential NCLEX Review

A client reports severe pain two days after surgery. After assessing the characteristics of the pain, which initial action should the nurse take next? 1 Encourage rest. 2 Obtain vital signs. 3 Administer the prescribed analgesic. 4 Document the client's pain response.

2 Obtain vital signs. Immediately before administration of an analgesic, an assessment of vital signs is necessary to determine whether any contraindications to the medication exist (e.g., hypotension, respirations ≤12 breaths/min). Pain prevents both psychological and physiologic rest. Before administration of an analgesic, the nurse must check the health care provider's prescription, the time of the last administration, and the client's vital signs. A complete assessment including vital signs should be done before documenting.

A 6-month-old infant is to be on nothing-by-mouth (NPO) status for 4 hours before surgery for cleft palate repair. What is the most important concern for the infant before surgery? 1 Altered fluid intake before surgery 2 Difficulty of respiration caused by the cleft 3 Increased tension before the hospitalization 4 Regression related to the duration of hospitalization

Correct1 Altered fluid intake before surgery A 6-month-old, whose body weight is approximately 75% water, is very susceptible to fluid changes and ensuing dehydration. Although children with cleft palate breathe through the mouth, it does not impair their breathing; the surgery is performed before 2 years of age, before speech patterns become fixed, not because the cleft lip impairs breathing patterns. Although the parents may be anxious, the infant is too young to be aware of the impending hospitalization. Regressed behavior should not be a problem for a short-term hospitalization.

A child undergoes tonsillectomy and adenoidectomy for numerous recurrent respiratory tract infections. After the surgery, the nurse should teach the parents to: 1 Offer ice chips. 2 Encourage the intake of ice cream. 3 Keep the child in the supine position. 4 Gargle with a diluted mouthwash solution

Correct1 Offer ice chips. ice chips are soothing and promote vasoconstriction. Milk and milk products coat the mouth, causing the child to clear the throat, which may precipitate bleeding. The supine position promotes edema and does not allow oral secretions to drain from the mouth. The head of the bed should be elevated, and the child should be positioned on the side. Mouthwash solution is too caustic; a warm saltwater solution is preferred.

A nurse is assessing a client who has had a carotid endarterectomy. Which response does the nurse consider evidence of a complication of the surgery? 1 Decreased appetite 2 Impaired swallowing 3 Change in bowel habits 4 Slight edema of the neck

Correct2 Impaired swallowing Impaired swallowing may occur as result of cranial nerve damage during surgery. Slight edema of the neck is expected from the trauma of surgery; it is not a complication. Decreased appetite, change in bowel habits, and slight edema of the neck are not a complication of a carotid endarterectomy.

A client who has a history of angina is scheduled for a cardiac catheterization. Catheter entry will be through the femoral artery. The nurse informs the client that the client will: 1 Remain fully alert during the procedure 2 Ambulate shortly after the procedure 3 Experience a feeling of warmth during the procedure 4 Be placed in a semi-Fowler position for 12 hours after the procedure

Correct3 Experience a feeling of warmth during the procedure A warm flushing sensation that lasts approximately 30 seconds will occur when the contrast medium is injected. Medication is given for mild sedation; clients are drowsy but awake enough to follow instructions. The supine position will be maintained for four to six hours after the procedure; walking may dislodge clots at the catheter insertion site, resulting in bleeding. The semi-Fowler position flexes the legs, which may result in bleeding at the femoral insertion site and should be avoided.

A client has left hemiplegia because of a cerebrovascular accident (also known as "brain attack"). What can the nurse do to contribute to the client's rehabilitation? 1 Begin active exercises. 2 Make a referral to the physical therapist. 3 Position the client to prevent contractures. 4 Avoid moving the affected extremities unless necessary

Correct3 Position the client to prevent contractures To prevent contractures after a brain attack, the client should be positioned in functional alignment and passive range-of-motion exercises should be performed. Active exercises are impossible with paralyzed limbs. The health care provider must request a consult with the physical therapist. Avoid moving the affected extremities unless necessary will increase contractures and atrophy.

A client is admitted to the hospital with suspected liver disease, and a needle biopsy of the liver is performed. After the procedure, the nurse should maintain the client in what position? 1 Supine 2 Semi-Fowler 3 Right side-lying 4 Dorsal recumbent

Correct3 Right side-lying The liver is on the right side of the body; the right side-lying position provides pressure at the needle insertion site and promotes hemostasis. The supine position does not provide pressure over the liver or promote hemostasis. The semi-Fowler position does not provide pressure over the liver or promote hemostasis. The dorsal recumbent position keeps the liver uppermost, thus no pressure is exerted to promote hemostasis.

What is the priority nursing intervention during the 2 hours after a cesarean birth? 1 Evaluating fluid needs to maintain optimum hydration 2 Monitoring the incision to help prevent the onset of infection 3 Encouraging bonding to promote mother-infant interaction 4 Assessing the lochia to identify the complication of hemorrhage

Correct4 Assessing the lochia to identify the complication of hemorrhage The amount and character of the lochia must be checked after a cesarean birth just as they are after a vaginal birth. Although it is important to maintain hydration, preventing hemorrhage is the priority. Although the area of the incision is monitored for signs of hemorrhage, it is too early for evidence of infection. Bonding is an important consideration after the conditions of both mother and newborn have stabilized.

A nurse is caring for a client with glomerulonephritis. What should the nurse instruct the client to do to prevent recurrent attacks? 1 Take showers instead of tub baths. 2 Continue the same restrictions on fluid intake. 3 Avoid situations that involve physical activity. 4 Seek early treatment for respiratory tract infections.

Correct4 Seek early treatment for respiratory tract infections. Hemolytic streptococci, common in throat infections, can initiate an immune reaction that damages the glomeruli. Baths may be linked to urethritis, not glomerulonephritis. Fluid restriction is moderated as the client improves; fluid helps prevent urinary stasis. Activity helps prevent urinary stasis. Test-Taking Tip: Avoid choosing answers that use words such as always, never, must, all, and none. If you are confused about the question, read the choices, label them true or false, and choose the answer that is the odd one out (i.e., the one false one or the one true one). When a question is framed in the negative, such as "When assessing for pain, you should not," the false option is the correct choice.

A client is to undergo a tuberculin test as part of her prenatal workup. Before administering the test, what information about the client should the nurse obtain? 1 Whether she has had a previous tuberculin test 2 Whether the client is prone to respiratory diseases 3 Whether an earlier tuberculin test's result was positive 4 Whether the client's family has a history of tuberculosis

Whether an earlier tuberculin test's result was positive A tuberculin test should not be administered to a client with a previous positive result on a tuberculin test because a severe reaction may occur at the test site in a previously sensitized individual. It is more important to know whether the test result was positive than whether a test was performed. Being prone to respiratory diseases is not a contraindication to having a tuberculin test unless the client is infected with tuberculosis. Although a family history may have involved exposure of the client to tuberculosis, the client may not have had a positive tuberculin test result; also many years may have elapsed since the exposure.