a client has been receiving hydromorphone every six hours for four days what assessment should the nurse prioritize
Logo

Nursing Elites

HESI RN

RN HESI Exit Exam Capstone

1. A client has been receiving hydromorphone every six hours for four days. What assessment should the nurse prioritize?

Correct answer: B

Rationale: The correct answer is B. Hydromorphone can cause constipation, a common side effect of opioids. Therefore, it is crucial to auscultate bowel sounds to monitor for signs of decreased gastrointestinal motility. Monitoring blood pressure (choice C) and respiratory rate (choice D) are important but not the priority in this scenario as constipation is a common issue with opioid use. Increasing the dosage of the medication (choice A) is not appropriate without assessing the client's bowel function first.

2. The nurse is developing a teaching plan for a client receiving chemotherapy. Which of the following should be the nurse's first priority?

Correct answer: C

Rationale: The correct answer is C. Recognizing signs and symptoms of infection should be the nurse's first priority when developing a teaching plan for a client receiving chemotherapy. Chemotherapy often compromises the immune system, making patients more susceptible to infections. Early identification and prompt treatment of infections are crucial to prevent complications. Options A, B, and D are important aspects of care but recognizing signs of infection takes precedence due to the potential life-threatening consequences in clients undergoing chemotherapy treatment.

3. A client with chronic heart failure is admitted with worsening dyspnea. What is the nurse's priority action?

Correct answer: A

Rationale: In a client with chronic heart failure experiencing worsening dyspnea, the priority action for the nurse is to administer oxygen at 2 liters per nasal cannula. This helps improve oxygenation and alleviate respiratory distress. Administering a diuretic (Choice B) may be necessary but addressing oxygenation comes first. While assessing lung sounds (Choice C) is important, it is not the immediate priority when the client is in respiratory distress. Repositioning the client (Choice D) may help with comfort but does not address the underlying issue of inadequate oxygenation.

4. A client with acute pancreatitis is receiving intravenous fluids and pain medication. What is the priority assessment for this client?

Correct answer: D

Rationale: The correct answer is D: Monitor blood glucose levels. Clients with acute pancreatitis are prone to hyperglycemia due to impaired insulin production. Monitoring blood glucose levels is crucial to prevent complications like diabetic ketoacidosis. While assessing bowel sounds, urine output, and abdominal tenderness are important in the overall care of a client with acute pancreatitis, monitoring blood glucose levels takes priority to address the immediate risk of hyperglycemia.

5. Which of these findings would the nurse more closely associate with anemia in a 10-month-old infant?

Correct answer: B

Rationale: The correct answer is B. Pale mucous membranes, such as those of the eyelids and lips, are a classic sign of anemia in infants. Anemia leads to decreased oxygen-carrying capacity, resulting in tissue hypoxia, which can manifest as pale mucosa. Choice A, a hemoglobin level of 12 g/dL, is within the normal range for a 10-month-old infant and would not necessarily indicate anemia. Choice C, hypoactivity, is a non-specific finding and can be present in various conditions, not specifically anemia. Choice D, a heart rate between 140 to 160, is within the normal range for an infant and is not a specific finding associated with anemia.

Similar Questions

A client admitted to the ICU with Syndrome of Inappropriate Antidiuretic Hormone (SIADH) has developed osmotic demyelination. What is the first intervention the nurse should implement?
What symptoms suggest the dosage of levothyroxine sodium is too high in a 26-year-old client with simple goiter?
The nurse is providing discharge instructions to a client with chronic venous insufficiency. Which recommendation should the nurse include to help prevent complications?
A client is admitted with pneumonia and is started on antibiotics. After 3 days, the client reports difficulty breathing and a rash. What is the nurse's first action?
Which medication should the nurse withhold if the client's serum potassium level is 6.2 mEq/L?

Access More Features

HESI RN Basic
$89/ 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