a client with a spinal cord injury at the t1 level is admitted with a suspected deep vein thrombosis dvt in the right leg which intervention should th
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HESI RN

HESI RN Exit Exam 2024 Quizlet

1. A client with a spinal cord injury at the T1 level is admitted with a suspected deep vein thrombosis (DVT) in the right leg. Which intervention should the nurse implement first?

Correct answer: B

Rationale: The correct answer is to place the client on bedrest. Placing the client on bedrest is the priority intervention as it helps prevent the risk of embolization from the DVT, which could lead to a life-threatening pulmonary embolism. Administering anticoagulant therapy, elevating the client's right leg, or applying compression stockings are important interventions in managing DVT but should come after ensuring the client is on bedrest to prevent the dislodgment of the clot.

2. A client with a head injury is receiving mechanical ventilation. Which finding indicates to the nurse that the client may be experiencing increased intracranial pressure (ICP)?

Correct answer: D

Rationale: In a client with increased intracranial pressure (ICP), the body's compensatory mechanisms lead to an elevation in blood pressure and a widening pulse pressure. This occurs due to the body's attempt to maintain cerebral perfusion. Therefore, elevated blood pressure and widening pulse pressure are classic signs of increased ICP and necessitate immediate attention. Choices A, B, and C are incorrect because a widening pulse pressure, sudden drop in heart rate, or decreased urine output are not specific indicators of increased ICP.

3. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine, and the UAP is placing soft pillows along the side rails. What action should the nurse take?

Correct answer: B

Rationale: The nurse should instruct the UAP to pad the side rails with soft blankets instead of pillows. Placing pillows along the side rails could lead to suffocation during a seizure and would need to be removed promptly. Instructing the UAP to use soft blankets is safer as they can help prevent injury without posing a risk of suffocation. Ensuring effective placement of the pillows (Choice A) is not appropriate as pillows should not be used in this situation. Assuming responsibility for placing the pillows (Choice C) or propping the client in a side-lying position with pillows (Choice D) are both unsafe actions and could potentially harm the client.

4. The nurse is triaging several children as they present to the emergency room after an accident. Which child requires the most immediate intervention by the nurse?

Correct answer: A

Rationale: The correct answer is A. Projectile vomiting in a child with a headache could indicate increased intracranial pressure, requiring immediate attention. Choices B, C, and D do not present with symptoms indicating potentially life-threatening conditions that require urgent intervention.

5. In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse (PN)?

Correct answer: D

Rationale: The best client for the charge nurse to assign to a practical nurse (PN) is an older client post-stroke who is aphasic with right-sided hemiplegia. This client is stable and suitable for care by a PN under supervision. Choices A, B, and C present clients with more complex and acute conditions that would require a higher level of nursing expertise and intervention.

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