a client is admitted with a suspected bowel obstruction what assessment finding should the nurse report immediately
Logo

Nursing Elites

HESI RN

HESI RN Exit Exam 2024 Quizlet Capstone

1. A client is admitted with a suspected bowel obstruction. What assessment finding should the nurse report immediately?

Correct answer: B

Rationale: A distended abdomen with a firm, rigid feel is a concerning sign that suggests a complication such as bowel perforation, which requires immediate intervention. Absent bowel sounds can be expected in bowel obstructions but are not as urgent as a rigid abdomen. Frequent episodes of nausea and vomiting are common with bowel obstructions but do not indicate an immediate life-threatening complication. Hyperactive bowel sounds and abdominal cramping are more indicative of bowel obstruction rather than a complication requiring immediate attention.

2. A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern?

Correct answer: B

Rationale: Fixed, dilated pupils are a sign of increased intracranial pressure or brain injury, indicating a potentially serious neurological condition. Flaccid paralysis, although concerning, may not always indicate immediate life-threatening issues. Diminished spinal reflexes and reduced sensory responses are important neurological assessments but are not as acutely concerning as fixed, dilated pupils in this context.

3. The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to

Correct answer: A

Rationale: Weight-bearing exercises are crucial in managing osteoporosis as they help strengthen bones. Choice A is the correct answer because weight-bearing activities, such as walking, dancing, or weight training, help stimulate bone formation and strengthen bones, which is essential in managing osteoporosis. Choice B is incorrect as the primary focus should be on the type of exercise rather than weight reduction. Choice C is incorrect because avoiding exercise altogether can lead to further bone density loss, and it is important to engage in safe weight-bearing activities. Choice D is incorrect as the primary goal of exercise in osteoporosis is to improve bone density through weight-bearing activities.

4. A client with diabetes mellitus is experiencing diabetic ketoacidosis (DKA). What laboratory result should the nurse monitor closely?

Correct answer: B

Rationale: A blood glucose level of 320 mg/dL indicates the need for insulin to manage diabetic ketoacidosis.

5. When assessing constipation in elders, what action should be the nurse's priority?

Correct answer: B

Rationale: Obtaining a detailed health and dietary history is crucial when assessing constipation in elders. This helps the nurse identify potential causes such as inadequate fluid intake, low fiber diet, lack of physical activity, or medications that could be contributing to constipation. A complete blood count (Choice A) is not the priority in the initial assessment of constipation. Referring to a provider for a physical examination (Choice C) would be done after gathering more information from the health history. Measuring height and weight (Choice D) is not directly relevant to assessing constipation and identifying its causes.

Similar Questions

The nurse is caring for a client with a nasogastric tube. Which of the following interventions is a priority to maintain client safety?
A client presents with severe dehydration due to prolonged vomiting. What is the nurse's priority intervention?
A child has a nosebleed (epistaxis) while playing soccer. In what position should the nurse place the child?
A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?
While auscultating heart sounds, the nurse hears a swishing sound. How should this sound be documented?

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