a client presents at the clinic with blepharitis what instructions should the nurse provide for home care
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Nursing Elites

HESI RN

RN HESI Exit Exam

1. A client presents at the clinic with blepharitis. What instructions should the nurse provide for home care?

Correct answer: D

Rationale: The correct answer is D. Blepharitis is managed with warm moist compresses to help loosen debris and oils on the eyelids, followed by gentle scrubbing with a mild solution like diluted baby shampoo. This helps in controlling the condition. Choice A is incorrect as using eye patches while sleeping is not a standard recommendation for blepharitis. Choice B is incorrect as wearing sunglasses does not directly treat blepharitis but may help with light sensitivity. Choice C is incorrect as cold compresses are not typically used for blepharitis, as warm compresses are more effective in managing the condition.

2. A client with cirrhosis is admitted with jaundice and ascites. Which intervention should the nurse implement first?

Correct answer: B

Rationale: Administering lactulose is the first priority in managing a client with cirrhosis to reduce ammonia levels and prevent worsening hepatic encephalopathy. Lactulose helps in decreasing the absorption of ammonia in the intestines and promotes its excretion through the stool. This intervention is crucial in preventing the development or progression of hepatic encephalopathy. Administering a diuretic (Choice A) may be necessary to manage ascites, but it is not the priority over lactulose in this scenario. Monitoring the client's weight (Choice C) is important to assess fluid retention but is not the first intervention required. Assessing the client's neurological status (Choice D) is essential in cirrhosis, but administering lactulose takes precedence to prevent hepatic encephalopathy.

3. In a client with liver cirrhosis admitted with ascites and jaundice, which laboratory value is most concerning to the nurse?

Correct answer: C

Rationale: An elevated ammonia level of 80 mcg/dl is most concerning in a client with liver cirrhosis because it may indicate hepatic encephalopathy, a serious complication. Serum albumin, though low, is expected in cirrhosis and contributes to ascites. Bilirubin elevation is common in liver disease but may not be the most concerning in this case. Prothrombin time is typically prolonged in liver disease but may not be as acute as an elevated ammonia level suggesting hepatic encephalopathy.

4. A client with cirrhosis is admitted with jaundice and ascites. Which assessment finding requires immediate intervention?

Correct answer: B

Rationale: Confusion and altered mental status are the most critical assessment findings in a client with cirrhosis. These symptoms may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Yellowing of the skin (jaundice) is a common manifestation of cirrhosis and does not necessitate immediate intervention. Peripheral edema and increased abdominal girth are associated with fluid retention in cirrhosis but are not as urgent as addressing altered mental status and confusion.

5. An adult male who lives alone is brought to the Emergency Department by his daughter who found him unresponsive. Initial assessment indicated that the client has minimal respiratory effort, and his pupils are fixed and dilated. At the daughter's request, the client is intubated and ventilated. Which nursing intervention has the highest priority?

Correct answer: B

Rationale: Verifying whether the client has an executed living will is crucial to ensuring that his treatment preferences are followed. In this critical situation, knowing the client's wishes regarding medical interventions is paramount. Options A, C, and D are not the highest priority as they do not directly address the immediate need to determine the client's treatment preferences.

Similar Questions

During orientation, a newly hired nurse demonstrates suctioning of a tracheostomy in a skills class. After the demonstration, the supervising nurse expresses concern that the demonstrated procedure increased the client's risk for which problem?
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which laboratory value requires immediate intervention?
A client with a history of heart failure presents to the clinic with nausea, vomiting, yellow vision, and palpitations. Which finding is most important for the nurse to assess for this client?
A client with hypertension receives a prescription for enalapril, an angiotensin-converting enzyme (ACE) inhibitor. Which instruction should the nurse include in the medication teaching plan?
A client with cirrhosis is admitted with ascites and jaundice. Which clinical finding is most concerning?

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