a client has been taking oral corticosteroids for the past five days because of seasonal allergies which assessment finding is of most concern to the
Logo

Nursing Elites

HESI RN

HESI Medical Surgical Practice Exam Quizlet

1. A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse?

Correct answer: C

Rationale: The correct answer is C: Purulent sputum. Corticosteroids can suppress the immune system, increasing the risk of infections. Purulent sputum suggests a possible respiratory infection, which can rapidly progress and lead to complications, making it the most concerning finding. Choice A, a white blood count of 10,000/mm³, is within the normal range and not typically a cause for immediate concern. Choice B, a serum glucose level of 115 mg/dL, is also normal and not directly related to corticosteroid use. Choice D, excessive hunger, is a common side effect of corticosteroids but is not as concerning as a sign of infection indicated by purulent sputum.

2. The healthcare professional assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory results should the healthcare professional review?

Correct answer: B

Rationale: The platelet count is the most appropriate laboratory result to review in a client presenting with petechiae and ecchymosis. Petechiae and ecchymosis are indicative of potential bleeding issues, which can be caused by low platelet count or impaired platelet function. Platelets are essential for clotting, and a low platelet count can lead to bleeding disorders. Reviewing the platelet count will provide valuable information about the client's clotting ability. Choice A, red blood cell count, is not typically associated with petechiae and ecchymosis. Hemoglobin levels (Choice C) are more related to anemia than bleeding disorders like thrombocytopenia. White blood cell count (Choice D) is not directly linked to the presence of petechiae and ecchymosis, which are more specific to platelet-related issues.

3. The client is planning care for a client who is receiving hemodialysis. Which of the following interventions should be included in the plan of care?

Correct answer: B

Rationale: Monitoring for signs of infection is crucial in clients receiving hemodialysis because they are at an increased risk of infection due to the invasive nature of the procedure. Administering anticoagulants is not typically a part of the routine care for clients undergoing hemodialysis unless specifically prescribed. While a high-protein diet may be beneficial for some clients, it is not a specific intervention related to hemodialysis. Encouraging fluid intake must be individualized based on the client's fluid status and should not be a generalized recommendation for all clients receiving hemodialysis.

4. The nurse is caring for a patient who has had severe vomiting. The patient’s serum sodium level is 130 mEq/L. The nurse will expect the patient’s provider to order which treatment?

Correct answer: C

Rationale: In this scenario, the patient has hyponatremia with a serum sodium level of 130 mEq/L. For a serum sodium level between 125 and 135 mEq/L, the appropriate treatment is intravenous normal saline 0.9%. Normal saline helps to increase the sodium content in the vascular fluid. Diuretic therapy would exacerbate sodium and fluid depletion, which is not suitable for a patient already dehydrated from severe vomiting. Intravenous hypertonic 5% saline is typically reserved for severe hyponatremia with a serum sodium level below 120 mEq/L. Oral sodium supplements are not feasible in this case as the patient is vomiting and may not be able to tolerate oral intake easily.

5. A client is placed on fluid restrictions because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the client’s fluid balance is stable at this time?

Correct answer: C

Rationale: The absence of adventitious sounds upon auscultation of the lungs is a key indicator that the client's fluid balance is stable. Adventitious sounds, such as crackles or wheezes, are typically heard in conditions of fluid overload, indicating that the body is retaining excess fluid. Choices A and B, decreased calcium levels and increased phosphorus levels, are common laboratory findings associated with chronic kidney disease (CKD) and are not directly related to fluid balance. Increased edema in the legs is a sign of fluid imbalance, suggesting fluid retention in the tissues, which would not indicate stable fluid balance in a client with CKD on fluid restrictions.

Similar Questions

A nurse performing nasopharyngeal suctioning suddenly notes the presence of bloody secretions. What should the nurse do first?
When working with a large population of African-American clients at a community health center, which priority assessment should a nurse include?
Why is lactated Ringer’s solution given to a patient experiencing vomiting and diarrhea?
When a young client being taught to use an inhaler for asthma symptoms states the intention to use the inhaler but plans to continue smoking cigarettes, what is the best initial action by the nurse?
A patient has been taking spironolactone (Aldactone) to treat heart failure. The nurse will monitor for

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