a client is being discharged with a prescription for chlorpromazine thorazine before leaving for home which of these findings should the nurse teach t
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Nursing Elites

HESI RN

HESI Nutrition Practice Exam

1. A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report?

Correct answer: B

Rationale: The correct answer is B: "Sore throat and fever." These symptoms can indicate a serious side effect of chlorpromazine and should be reported immediately. Choices A, C, and D are incorrect because they are not typically associated with adverse effects of chlorpromazine. Changes in libido and breast enlargement are not commonly linked to this medication. Abdominal pain, nausea, and diarrhea are more likely to be gastrointestinal side effects. Dyspnea and nasal congestion are not commonly reported adverse effects of chlorpromazine.

2. The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?

Correct answer: C

Rationale: Repositioning every two hours is the most effective measure in preventing skin breakdown for a client with a CVA. This practice helps to relieve pressure on the skin, reducing the risk of pressure ulcers. Placing the client in a wheelchair for extended periods (Choice A) can increase pressure on specific areas, leading to skin breakdown. Padding bony prominences (Choice B) can provide some protection but may not address the root cause of pressure ulcers. Massaging reddened bony prominences (Choice D) can potentially worsen the condition by causing further damage to already compromised skin.

3. When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote

Correct answer: B

Rationale: Effective pain management encourages deep breathing and coughing, which are crucial for preventing complications after thoracic surgery. These actions help prevent respiratory complications such as pneumonia and atelectasis, promote lung expansion, and improve oxygenation. While relaxation and sleep are important for recovery, the priority after a thoracotomy and lobectomy is to prevent respiratory issues. Incisional healing is important but not the primary focus immediately post-surgery. Range of motion exercises are not directly related to promoting recovery after thoracic surgery.

4. A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these?

Correct answer: D

Rationale: The correct answer is to have gloves on while handling bedpans with feces. Hepatitis A is transmitted through the fecal-oral route, and using gloves during such direct contact with feces is crucial in preventing the transmission of the infection. Choice A is not directly related to infection control for hepatitis A. Choice B is more relevant to preventing droplet transmission rather than fecal-oral transmission. Choice C is important for preventing contact transmission from soiled linens but is not as directly related to the mode of transmission of hepatitis A as using gloves when handling feces.

5. A client with a history of seizures is being monitored with an electroencephalogram (EEG). Which of these interventions should the nurse perform to prepare the client for the test?

Correct answer: A

Rationale: Instructing the client to avoid caffeine for 8 hours before the EEG is essential. This intervention helps ensure accurate test results by preventing stimulation of the nervous system, which could interfere with the interpretation of the brain's electrical activity. Explaining the procedure and obtaining consent are important steps but do not directly impact the test results. Administering anticonvulsant medication as ordered is a medical intervention and not a preparation step for the test. Instructing the client to wash their hair the morning of the test is not necessary for EEG preparation.

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