a client who is gravida 1 para 0 is admitted to the birthing suite in early labor and requests pain relief which action should the nurse implement
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Nursing Elites

HESI RN

HESI RN CAT Exit Exam 1

1. A client who is gravida 1, para 0, is admitted to the birthing suite in early labor and requests pain relief. Which action should the nurse implement?

Correct answer: D

Rationale: In this scenario, the correct action for the nurse to implement is to administer an opioid analgesic as prescribed. Since the client is in early labor and requesting pain relief, opioids are commonly used to provide effective pain relief during labor. Encouraging distraction or teaching relaxation techniques may not be sufficient for pain management during labor, especially in the early stages when the pain intensity can increase rapidly. Determining the pain level and location is important but administering the prescribed opioid is the most appropriate action to address the client's request for pain relief.

2. The nurse is caring for a 10-year-old diagnosed with acute glomerulonephritis. Which outcome is the priority for this child?

Correct answer: D

Rationale: In acute glomerulonephritis, maintaining fluid balance is the priority to prevent complications like fluid overload or dehydration. Monitoring urine output within the range of 1 to 2 ml/kg/hr is crucial in assessing renal function. While activity tolerance, skin integrity, and nutritional status are important aspects of care, fluid balance takes precedence due to its direct impact on the renal condition and overall health outcome for the child.

3. A 14-year-old girl with asthma complains of feeling nervous and jittery after a respiratory therapy bronchodilator treatment. What explanation is best for the nurse to provide to this adolescent?

Correct answer: C

Rationale: The correct answer is C because a fast heart rate and jitteriness are common side effects of bronchodilators like albuterol. Choice A is incorrect as nervousness is more likely a side effect of the medication than solely related to hypoxia. Choice B is incorrect as it provides a partial explanation focusing only on tremors and heart rate, not mentioning jitteriness. Choice D is incorrect because excessive coughing and tachypnea are not typically associated with bronchodilator use; instead, they may indicate inadequate relief or other issues.

4. When obtaining a urine specimen from a female infant, which intervention should the nurse implement?

Correct answer: D

Rationale: When obtaining a urine specimen from a female infant, securing the pediatric urine collector bag to the perineum is the most appropriate intervention. This method allows for non-invasive collection of urine without causing discomfort or distress to the infant. Placing the wet diaper in a biohazard specimen bag (Choice A) is incorrect as it does not involve collecting a fresh urine sample. Using a catheter (Choice B) is invasive and not typically necessary for routine urine specimen collection from infants. Collecting the urinary stream in mid-air when the infant cries (Choice C) is not a reliable or hygienic method of obtaining a urine specimen.

5. A client diagnosed with a deep vein thrombus (DVT) followed by a diagnosis of pulmonary embolism (PE) is receiving heparin via an infusion pump at a rate of 1400 u/hour. The client tells the nurse, 'I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home'. What response is best for the nurse to provide?

Correct answer: A

Rationale: Choice A is the best response because it educates the client about the role of heparin in preventing future clot formation rather than dissolving the existing clot. This helps the client understand the medication's function and the importance of closely monitoring for signs of bleeding, a common side effect of heparin therapy. Choice B acknowledges the client's concern but does not provide accurate information about heparin's mechanism of action. Choice C is premature as it suggests transitioning to home therapy without addressing the client's concerns or explaining heparin's purpose. Choice D does not address the client's statement and instead questions their desire to leave the hospital.

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