a client is admitted with a large pleural effusion which procedure should the nurse prepare the client for
Logo

Nursing Elites

HESI RN

HESI RN Exit Exam 2024 Capstone

1. A client is admitted with a large pleural effusion. Which procedure should the nurse prepare the client for?

Correct answer: A

Rationale: Corrected Rationale: The correct procedure for a client with a large pleural effusion is thoracentesis. Thoracentesis is a diagnostic and therapeutic procedure used to remove fluid from the pleural space, which can help relieve symptoms associated with pleural effusion. Choice B (Endotracheal intubation) is incorrect as it is a procedure to secure the airway by placing a tube into the trachea. Choice C (Chest tube insertion) is incorrect as it is typically done to drain air or fluid from the pleural space over a longer period. Choice D (Bronchoscopy) is incorrect as it is a procedure used to visualize the airways and diagnose lung conditions, not specifically for pleural effusion removal.

2. A client with heart failure is receiving furosemide. What assessment finding indicates the medication is effective?

Correct answer: C

Rationale: The correct answer is C: 'Decreased edema and improved peripheral pulses.' In a client with heart failure, furosemide is a diuretic that helps reduce fluid overload. Therefore, a decrease in edema (swelling due to fluid retention) and improved peripheral pulses (indicating better circulation) are signs that the medication is effective. Choices A, B, and D are incorrect. Increased urine output and weight loss (Choice A) may indicate the diuretic effect of furosemide but do not specifically reflect its effectiveness in heart failure. Increased heart rate and blood pressure (Choice B) are not desired effects of furosemide and may suggest adverse reactions. Decreased shortness of breath and clear lung sounds (Choice D) are related to improved respiratory status and may not directly reflect the effectiveness of furosemide in addressing fluid overload.

3. The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow-up rather than delegate care to the nursing assistant?

Correct answer: C

Rationale: A change in responsiveness, as indicated by being minimally responsive to voice and touch, suggests a potential acute issue that requires immediate nursing assessment and intervention rather than delegation. Changes in vital signs (choices A, B, D) can be important but do not always indicate an immediate need for nursing intervention compared to a change in responsiveness.

4. A client with cirrhosis is receiving lactulose. What is the most important assessment for the nurse to monitor?

Correct answer: D

Rationale: The correct answer is to monitor the client's level of consciousness. Lactulose is used to reduce ammonia levels in hepatic encephalopathy. Monitoring the level of consciousness helps assess the effectiveness of lactulose therapy in improving the client's condition. Monitoring ammonia levels (choice A) is important, but assessing the client's response to therapy through their level of consciousness is more crucial. Blood glucose levels (choice B) and potassium levels (choice C) are not directly related to lactulose therapy for cirrhosis and hepatic encephalopathy.

5. The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the UAP?

Correct answer: D

Rationale: The UAP can be tasked with reporting complaints, monitoring weight gain, and tracking food and fluid intake, all of which are important in managing a client with Cushing's syndrome. These tasks fall within the UAP's scope of practice. Reporting client complaints helps in early identification of complications, monitoring weight is crucial due to fluid retention in Cushing's syndrome, and tracking food and fluid intake assists in dietary management. Choices A, B, and C are all necessary components of care for a client with Cushing's syndrome, making option D the correct answer.

Similar Questions

A client with a prescription for DNR begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?
A client with antisocial personality disorder repeatedly requests a specific nurse be assigned to him and is belligerent when another nurse is assigned. What action should the charge nurse implement?
A 5-week-old infant with hypertrophic pyloric stenosis has developed projectile vomiting over the last two weeks. Which intervention should the nurse plan to implement?
The healthcare provider prescribes an IV infusion of isoproterenol in D5W at 300 mcg/hour. How many ml/hour should the nurse set the pump to?
A young male client is admitted to rehabilitation following a right above-knee amputation (AKA) and reports aching in his right foot. Which intervention is most important for the nurse to implement?

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