a client is recovering from an appendectomy for a ruptured appendix has a surgical wound healing by secondary intention when changing the clients dres
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Nursing Elites

HESI LPN

HESI Fundamentals Exam Test Bank

1. When changing the client's dressing, which observation should the nurse report to the client's surgeon for a client recovering from an appendectomy for a ruptured appendix with a surgical wound healing by secondary intention?

Correct answer: A

Rationale: A halo of erythema on the surrounding skin may indicate an infection or inflammation of the wound site, which is critical to report to the surgeon. Erythema, redness, and warmth are signs of inflammation that could potentially be a sign of an infected wound. Serous drainage is a common and expected finding in healing wounds, indicating a normal healing process. Edema around the wound might be expected due to the body's response to tissue injury. The absence of granulation tissue in a wound healing by secondary intention may not be an immediate concern as it forms during the later stages of wound healing.

2. A client has a new prescription for a metered-dose inhaler. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct instruction for using a metered-dose inhaler is to hold your breath for 10 seconds after inhaling the medication. This allows the medication to be absorbed more effectively in the lungs. Inhaling quickly and deeply while pressing down on the inhaler (Choice A) may cause the medication to deposit in the mouth and throat rather than reaching the lungs. Exhaling immediately after inhaling the medication (Choice C) may also lead to medication wastage. Shaking the inhaler before each use (Choice D) is not necessary for all types of inhalers and can sometimes cause improper drug delivery.

3. A 25-year-old primigravida at 16 weeks gestation is admitted to the hospital with a diagnosis of hyperemesis gravidarum. Which nursing diagnosis should have the highest priority?

Correct answer: A

Rationale: In a case of hyperemesis gravidarum, the priority nursing diagnosis should be addressing the Fluid volume deficit. This condition can lead to serious complications such as electrolyte imbalances and dehydration, which can endanger both the mother and the fetus if not managed promptly. Altered nutrition: less than body requirements is important but addressing the fluid volume deficit takes precedence as it poses an immediate threat. Anxiety related to new situational crisis and Activity intolerance related to fatigue are valid concerns, but they are secondary to the critical issue of fluid volume deficit in this scenario.

4. When providing mouth care for an unconscious client, what action should the nurse take?

Correct answer: A

Rationale: When providing mouth care for an unconscious client, the nurse should turn the client’s head to the side. This action helps prevent aspiration by allowing any fluids to drain out of the mouth, reducing the risk of choking or aspiration pneumonia. Placing fingers into the client’s mouth can be dangerous and may cause injury. Brushing the client’s teeth only once a day may not be sufficient for proper oral hygiene care. Injecting mouth rinse into the center of the mouth is not recommended and can potentially lead to aspiration. Therefore, the correct action for the nurse to take is to turn the client’s head to the side.

5. A nurse is teaching the parents of a toddler about discipline. Which of the following actions should the nurse suggest?

Correct answer: A

Rationale: The correct answer is to establish consistent boundaries for the toddler. This approach helps toddlers understand expectations and promotes consistent behavior. Placing the toddler alone or using food rewards may not effectively teach discipline and could be inappropriate. Informing the toddler about feelings when misbehaving may not be developmentally appropriate for a toddler to understand the consequences of their actions.

Similar Questions

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An older adult client has been hospitalized on bed rest for 1 week. The client reports elbow pain. Which of the following is an appropriate initial action for the nurse caring for this client to take?
While documenting in a client’s medical record, which of the following entries should the nurse record?
When should the nurse plan to collect a sputum specimen for culture and sensitivity as ordered by a client's provider?

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