a client who had surgery yesterday is becoming increasingly anxious the clients respiratory rate has increased to 38 breathsminute the client has a na
Logo

Nursing Elites

HESI LPN

HESI Test Bank Medical Surgical Nursing

1. A client who had surgery yesterday is becoming increasingly anxious. The client’s respiratory rate has increased to 38 breaths/minute. The client has a nasogastric tube to low intermittent suction with 500 ml of yellow-green drainage over the last four hours. The client's arterial blood gases (ABGs) indicate a decreased CO2 and an increased serum pH. Which serum laboratory value should the nurse monitor first?

Correct answer: A

Rationale: The correct answer is A, Electrolytes. In this scenario, the client is at risk for metabolic alkalosis due to the loss of gastric secretions through the nasogastric tube. Monitoring electrolytes is crucial to assess the levels of sodium, potassium, chloride, and bicarbonate, which are important in maintaining the acid-base balance of the body. Changes in these electrolyte levels can provide valuable information about the client's fluid status and acid-base balance. Creatinine, blood urea nitrogen, and glucose levels are important parameters to monitor in different situations but are not the priority in this case of potential metabolic alkalosis.

2. The nurse determines that an adult client who is admitted to the post-anesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6°F (34.4°C), a pulse rate of 88 beats/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/68 mmHg. Which action should the nurse implement?

Correct answer: D

Rationale: Taking the temperature using another method is essential in this situation to verify if the low reading is accurate and requires further intervention. The tympanic temperature of 94.6°F may be inaccurate due to various factors such as improper technique or environmental conditions. Checking the blood pressure every five minutes for one hour (Choice A) is not the priority in this case as the low blood pressure reading alone does not necessitate such frequent monitoring. Raising the head of the bed 60 to 90 degrees (Choice B) is not directly related to addressing the low temperature and blood pressure. Asking the client to cough and deep breathe (Choice C) is a general intervention that may not directly address the specific concern of the low temperature reading.

3. Laboratory findings indicate that a client’s serum potassium level is 2.5 mEq/L. What action should the nurse take?

Correct answer: C

Rationale: A serum potassium level of 2.5 mEq/L is critically low, indicating severe hypokalemia. In this situation, it is essential for the nurse to inform the healthcare provider promptly about the need for potassium replacement. Administering potassium supplements orally or increasing dietary potassium intake is not appropriate in cases of critically low potassium levels as immediate and precise replacement is necessary. Monitoring the client's ECG continuously is important in severe cases of hypokalemia, but the priority action should be to inform the healthcare provider for further management and treatment.

4. What is the priority patient problem for the parents of a newborn born with cleft lip and palate?

Correct answer: C

Rationale: The correct answer is C: Risk for impaired attachment. Parents of a newborn with cleft lip and palate may face challenges in bonding with their child due to the physical appearance, impacting attachment. Promoting bonding between parents and the infant is crucial in this situation. Choice A (Parental role conflict) is incorrect as it focuses on conflicting roles rather than the attachment issue. Choice B (Risk for delayed growth and development) is not the priority issue in this scenario as the immediate concern is establishing a healthy attachment. Choice D (Anticipatory grieving) is not the priority patient problem as it pertains more to the emotional response to an anticipated loss, which is not the primary concern at this stage.

5. A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the healthcare provider?

Correct answer: C

Rationale: Hematuria is the most important assessment finding to report to the healthcare provider in a client with SLE during an exacerbation. Hematuria indicates kidney involvement, a serious complication of SLE that requires prompt medical attention. While low-grade fever, muscle atrophy, and joint pain are symptoms that can occur in SLE, hematuria signifies potential renal damage, which is a critical concern in SLE exacerbations.

Similar Questions

A new mother asks the clinic nurse if she must continue giving her baby nystatin for thrush since the white lesions on his tongue have disappeared. What response by the nurse is most appropriate?
The nurse is providing discharge teaching for a client with heart failure. Which instruction should be included to prevent fluid overload?
What assessment findings should lead the nurse to suspect Down syndrome in a newborn?
A client who is newly diagnosed with emphysema is being prepared for discharge. Which instruction is best for the nurse to provide the client to assist them with dyspnea self-management?
While walking to the mailbox, an older adult male experiences sudden chest tightness and drives himself to the emergency department. When the client gets up to the desk of the triage nurse, he says his heart is pounding out of his chest as he clutches his chest and falls to the floor. Which intervention should the nurse implement first?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses