a client is admitted with a suspected gastrointestinal bleed what assessment finding requires immediate intervention
Logo

Nursing Elites

HESI RN

HESI 799 RN Exit Exam Capstone

1. A client is admitted with a suspected gastrointestinal bleed. What assessment finding requires immediate intervention?

Correct answer: D

Rationale: Dark, tarry stools indicate the presence of digested blood in the gastrointestinal tract, signifying a higher gastrointestinal bleed. This finding requires immediate intervention due to the potential severity of the bleed. Bright red blood in the vomit may indicate active bleeding but is not as concerning as digested blood. Elevated blood pressure and heart rate are common responses to bleeding but do not provide direct evidence of the source or severity of the bleed. Coffee ground emesis is indicative of partially digested blood and is a concern but not as urgent as dark, tarry stools.

2. The nurse is providing discharge teaching to a client with gastroesophageal reflux disease (GERD). Which instruction should the nurse include in the teaching?

Correct answer: C

Rationale: The correct instruction for the nurse to include in the teaching for a client with GERD is to eat small, frequent meals throughout the day. This recommendation helps reduce symptoms by preventing the stomach from becoming overly full, which can increase pressure on the lower esophageal sphincter and lead to acid reflux. Choices A, B, and D are incorrect because increasing fluid intake with meals can exacerbate GERD symptoms, lying down after eating can worsen reflux, and consuming spicy foods can trigger acid reflux in individuals with GERD.

3. While changing a client's chest tube dressing, the nurse notes a cracking sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take?

Correct answer: D

Rationale: When a nurse observes crepitus around a chest tube site, it could indicate subcutaneous emphysema, a potentially serious condition where air gets trapped under the skin. Measuring the area of swelling and crackling is important as it helps monitor the progression of subcutaneous emphysema. Applying a pressure dressing (choice A) might not address the underlying cause and could potentially worsen the condition. Administering an oral antihistamine (choice B) is not indicated for crepitus at a chest tube site. Assessing for allergies to topical cleaning agents (choice C) is important but not the immediate priority when crepitus is observed.

4. The nurse is providing discharge instructions to a client with chronic venous insufficiency. Which recommendation should the nurse include to help prevent complications?

Correct answer: B

Rationale: The correct recommendation for a client with chronic venous insufficiency to prevent complications is to wear compression stockings. Compression stockings help improve venous circulation and prevent the worsening of symptoms. While elevating the legs is also beneficial, the priority intervention in preventing complications is wearing compression stockings. Using a heating pad on the legs can actually worsen the condition by dilating blood vessels, and massaging the legs daily can potentially damage fragile skin in clients with chronic venous insufficiency.

5. A client with a history of atrial fibrillation is prescribed warfarin. What is the nurse's priority teaching?

Correct answer: B

Rationale: The correct answer is B: 'Avoid foods high in vitamin K.' Warfarin is an anticoagulant medication that works by interfering with vitamin K-dependent clotting factors. Therefore, consuming foods high in vitamin K can affect the medication's effectiveness. Choices A, C, and D are incorrect because: A) Warfarin is not affected by foods high in potassium; C) Warfarin should be taken with food to minimize gastrointestinal side effects; D) There is no specific requirement for taking warfarin at bedtime for best results.

Similar Questions

The nurse prepares a discharge plan for an older adult client following cataract extraction. What instructions should the nurse provide?
A client with COPD and a history of emphysema presents with increasing shortness of breath. What action should the nurse implement first?
A client presents to the clinic with concerns about her left breast. Which assessment finding is most important for the nurse to report?
A nurse is caring for a client with a chest tube following lung surgery. What is the most important intervention to ensure the chest tube functions properly?
A young male client with an above-knee amputation (AKA) reports that his 'right foot is aching.' What is the most important intervention 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