a client is tested for hiv with the use of an enzyme linked immunosorbent assay elisa and the test result is positive the nurse should tell the client
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Nursing Elites

HESI RN

HESI Medical Surgical Specialty Exam

1. A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse should tell the client that:

Correct answer: C

Rationale: When an ELISA test for HIV is positive, it is essential to confirm the result with a Western blot. The Western blot is the confirmatory test for HIV. Choice A is incorrect because a positive ELISA test does not confirm HIV infection. Choice B is incorrect as it assumes a different diagnosis. Choice D is incorrect because a positive ELISA test does indicate potential HIV infection and requires confirmation.

2. What is the priority assessment for a patient receiving intravenous morphine?

Correct answer: B

Rationale: The correct answer is monitoring the patient's respiratory rate. When a patient receives intravenous morphine, the priority assessment is to monitor the respiratory rate due to the risk of respiratory depression associated with morphine. This assessment helps in detecting and managing any potential respiratory complications promptly. Assessing blood pressure, checking pain level, and monitoring oxygen saturation are important aspects of patient care but are not the priority when considering the specific risk of respiratory depression with intravenous morphine.

3. A client arrived to the medical-surgical unit 4 hours after a transurethral resection of the prostate (TURP). A triple-lumen catheter for continuous bladder irrigation with normal saline is infusing, and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?

Correct answer: C

Rationale: In this scenario, the nurse should choose option C - irrigating the catheter manually. This action can help clear the clots from the catheter and ensure proper bladder drainage. Monitoring catheter drainage (option A) alone may not address the issue of clots obstructing the flow. Decreasing the flow rate (option B) could potentially worsen clot formation. Discontinuing the infusing solution (option D) without addressing the clots first may lead to inadequate irrigation and increase the risk of complications.

4. A client with an oversecretion of renin has a health history reviewed by a nurse. Which disorder should the nurse correlate with this assessment finding?

Correct answer: B

Rationale: Renin is secreted in response to low blood volume, blood pressure, or blood sodium levels. Excessive renin secretion can lead to persistent hypertension. Renin plays no role in Alzheimer's disease, diabetes mellitus, or viral hepatitis. Therefore, the correct correlation with oversecretion of renin is hypertension.

5. To assess the quality of an adult client's pain, what approach should the nurse use?

Correct answer: B

Rationale: The correct answer is to ask the client to describe the pain. This approach allows the nurse to gather subjective information directly from the client, such as the quality, intensity, location, and factors that aggravate or alleviate the pain. Observing body language and movement (Choice A) can provide additional cues but may not fully capture the client's pain experience. Identifying effective pain relief measures (Choice C) and providing a numeric pain scale (Choice D) are important aspects of pain management but do not directly assess the quality of the client's pain.

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