a client is 2 days post op from a thoracic surgery and is complaining of incisional pain the client last received pain medication 2 hours ago he is ra
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Nursing Elites

HESI RN

HESI Quizlet Fundamentals

1. A client is 2 days post-op from thoracic surgery and is complaining of incisional pain. The client last received pain medication 2 hours ago. He is rating his pain as a 5 on a 1-10 scale. After calling the provider, what is the nurse's next action?

Correct answer: A

Rationale: In this scenario, since no additional pain medication is available, the nurse should recommend non-pharmacological pain management techniques. Guided imagery and slow rhythmic breathing can help the client manage incisional pain effectively. These techniques can provide distraction and relaxation, potentially reducing the perception of pain without the need for additional medication.

2. Prior to Mr. Landon undergoing a tracheostomy, what is the top nursing priority?

Correct answer: B

Rationale: Before Mr. Landon undergoes a tracheostomy, the top nursing priority is to establish a means of communication. This is essential to ensure that Mr. Landon can effectively communicate his needs during and after the procedure. Shaving the neck (Choice A) may be necessary for the tracheostomy but is not the top priority. Inserting a Foley catheter (Choice C) and starting an IV (Choice D) are important nursing interventions but are not the priority before a tracheostomy procedure, where communication is key for patient safety and comfort.

3. When bathing an uncircumcised boy older than 3 years, which action should the nurse take?

Correct answer: C

Rationale: The correct action when bathing an uncircumcised boy older than 3 years is to gently retract the foreskin to cleanse the penis. This is important to ensure proper hygiene and prevent the accumulation of bacteria that can lead to infections. It is not advisable to defer perineal care because of the child's age, as hygiene is crucial at any age. Asking the parents about the circumcision status may not be relevant during routine perineal care. Reminding the child to clean his genital area is not as effective as directly cleaning the area during bathing.

4. When taking a client's blood pressure, the healthcare professional is unable to distinguish the point at which the first sound was heard. What is the best action for the healthcare professional to take?

Correct answer: C

Rationale: The correct action when unable to distinguish the point of the first sound during blood pressure measurement is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. This allows blood flow to return to the extremity, ensuring a more accurate reading the second time. It is important to ensure that the cuff is fully deflated and the appropriate wait time is given to obtain an accurate blood pressure measurement.

5. During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report?

Correct answer: D

Rationale: In response to the mother's report, the nurse should assess the family's home environment first to identify any factors that may hinder the establishment of bedtime routines conducive to sleep. Factors such as noise, light, distractions, or other environmental aspects could be contributing to the child's difficulty falling asleep at a reasonable hour and waking up in the morning.

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