a client who is bedridden after a stroke is at risk for developing pressure ulcers which nursing intervention is most important in preventing this com
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Nursing Elites

HESI RN

HESI RN Exit Exam Capstone

1. A client who is bedridden after a stroke is at risk for developing pressure ulcers. Which nursing intervention is most important in preventing this complication?

Correct answer: B

Rationale: Repositioning the client every 2 hours is crucial in preventing pressure ulcers in bedridden clients. This intervention helps in relieving pressure on specific areas of the body, promoting circulation, and reducing the risk of tissue damage. Applying lotion every 4 hours (Choice A) may not address the root cause of pressure ulcers. Elevating the head of the bed (Choice C) is beneficial for some conditions but not specifically targeted at preventing pressure ulcers. Massaging the skin at least twice a day (Choice D) can actually increase the risk of skin breakdown in individuals at risk for pressure ulcers by causing friction and shearing forces on the skin.

2. A 4-year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first?

Correct answer: A

Rationale: A pale foot with no pulse suggests a compromised blood supply, indicating a potential vascular emergency. The nurse's immediate priority is to notify the healthcare provider to address the situation promptly. Readjusting the traction, administering PRN medication, or waiting to reassess the foot later could lead to serious complications due to the compromised blood supply, making choices B, C, and D incorrect in this critical situation.

3. The client provides three positive responses to the CAGE questionnaire. Which interpretation should the nurse provide?

Correct answer: B

Rationale: The CAGE questionnaire is a widely used screening tool for alcohol dependence. Two or more positive responses suggest a higher likelihood of alcohol dependence. One positive response may indicate potential alcohol issues, but two or more significantly increase the likelihood of dependence. Therefore, choice B is the most appropriate interpretation. Choice A is incorrect because the CAGE questionnaire specifically focuses on alcohol-related issues, not substance abuse in general. Choice C is incorrect as one positive response does not indicate addiction but rather raises a concern. Choice D is incorrect as not all responses need to be positive to suggest alcohol dependence.

4. A client with chronic obstructive pulmonary disease (COPD) is experiencing difficulty breathing. What is the nurse's priority intervention?

Correct answer: B

Rationale: In clients with COPD experiencing difficulty breathing, increasing the client's oxygen flow rate is the priority intervention. This action helps to improve oxygenation and relieve shortness of breath. While bronchodilators and other medications may be necessary, providing immediate oxygen support is crucial. Elevating the head of the bed and repositioning the client can assist with breathing comfort but do not address the immediate need for improved oxygenation in COPD exacerbation.

5. What assessment is most important for the nurse to perform for a client with dehydration receiving IV fluids?

Correct answer: A

Rationale: The correct answer is to monitor the client’s electrolyte levels. When a client is receiving IV fluids for dehydration, it is crucial to assess their electrolyte levels regularly. Dehydration can lead to imbalances in electrolytes, especially sodium and potassium, which are essential for maintaining fluid balance and proper organ function. Checking urine output (Choice B) is important but not as critical as monitoring electrolyte levels. Assessing skin turgor (Choice C) is an indirect method of assessing dehydration but does not provide specific information about electrolyte imbalances. Monitoring blood pressure (Choice D) is important but not the most critical assessment in this scenario as electrolyte imbalances can have a more direct impact on the client's condition.

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