a 4 year old child falls off a tricycle and is admitted for observation how can the nurse best facilitate the childs cooperation during the assessment
Logo

Nursing Elites

HESI RN

HESI 799 RN Exit Exam Capstone

1. A 4-year-old child falls off a tricycle and is admitted for observation. How can the nurse best facilitate the child's cooperation during the assessment?

Correct answer: C

Rationale: Engaging the child in blowing out the penlight simulates play and can reduce fear, helping with cooperation during the assessment. Choice A is not recommended as it may increase anxiety by separating the child from the parent. Choice B is not appropriate as it involves playing with a syringe, which may not be safe or suitable. Choice D is not ideal for a 4-year-old child as understanding organ functions may be beyond their developmental level.

2. The healthcare provider is caring for a client with severe anemia. Which assessment finding requires immediate intervention?

Correct answer: C

Rationale: Shortness of breath is a critical sign in severe anemia as it indicates inadequate oxygenation, which can be life-threatening. Immediate intervention is necessary to address this condition. Pale skin (choice A) is a common finding in anemia but not as urgent as shortness of breath. Increased heart rate (choice B) is a compensatory mechanism in anemia to maintain oxygen delivery and is important but not as urgent as addressing inadequate oxygenation. Fatigue (choice D) is a common symptom in anemia but does not indicate an immediate life-threatening situation like shortness of breath does.

3. A male client with HIV on antiretroviral therapy complains of constant hunger and thirst while losing weight. What action should the nurse implement?

Correct answer: A

Rationale: The correct action for the nurse to implement is to check the client's glucose level with a glucometer. Constant hunger and thirst along with weight loss can be indicative of hyperglycemia, a possible side effect of saquinavir. Monitoring the client's glucose levels is crucial in this situation. Measuring the client's weight accurately (Choice B) is important for monitoring purposes but does not address the immediate concern of hunger, thirst, and weight loss. Reassuring the client that weight will stabilize as viral load decreases (Choice C) is not appropriate in this scenario as the symptoms described need immediate attention. Increasing the dose of saquinavir (Choice D) without assessing the client's glucose level can worsen the hyperglycemia.

4. A combination multi-drug cocktail is being considered for an asymptomatic HIV-infected client with a CD4 cell count of 500. Which nursing assessment of the client is most crucial in determining whether therapy should be initiated?

Correct answer: C

Rationale: The most crucial nursing assessment in determining whether therapy should be initiated for an asymptomatic HIV-infected client with a CD4 cell count of 500 is the client's willingness to comply with complex drug schedules. Adherence to antiretroviral therapy is essential for its effectiveness. Assessing the client's willingness and ability to comply with the complex medication regimen is crucial to ensure successful treatment and prevent drug resistance. Choices A, B, and D, although important in the overall care of the client, are not as crucial as assessing the client's willingness to adhere to the prescribed drug regimen.

5. The nurse is providing care for a client receiving total parenteral nutrition (TPN). Which action should the nurse include in the client's plan of care?

Correct answer: C

Rationale: The correct action the nurse should include in the client's plan of care is to monitor blood glucose levels regularly. Clients receiving TPN are at risk for hyperglycemia due to the high glucose content of the solution. Regular monitoring of blood glucose levels is essential to ensure appropriate management of blood sugar. Choice A is incorrect because increasing the TPN infusion rate based on hunger is not a valid parameter for adjusting TPN. Choice B is incorrect because TPN should be administered through a central line, not a peripheral IV line, to prevent complications. Choice D is incorrect because TPN solutions should be stored at room temperature, not refrigerated.

Similar Questions

Why is it important for the healthcare provider to monitor blood pressure in clients receiving antipsychotic drugs?
After administering a proton pump inhibitor, which action should the nurse take to evaluate the effectiveness of the medication?
A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)?
A client with a chest tube following a pneumothorax is complaining of increased shortness of breath. What is the nurse's first action?
On admission to the Emergency Department, a female client who was diagnosed with bipolar disorder 3 years ago reports that this morning, she took a handful of medications and left a suicide note for her family. Which information is most important for the nurse to obtain?

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