a client with a tracheostomy is experiencing thick tenacious secretions which intervention should the nurse implement first
Logo

Nursing Elites

HESI RN

HESI 799 RN Exit Exam

1. A client with a tracheostomy is experiencing thick, tenacious secretions. Which intervention should the nurse implement first?

Correct answer: C

Rationale: Increasing humidity in the client's room is the initial intervention for managing thick, tenacious secretions in a client with a tracheostomy. Adequate humidity helps to hydrate secretions, making them easier to clear, thus improving airway clearance. Encouraging fluid intake (Choice A) can be beneficial but is not the first-line intervention. Administering a mucolytic agent (Choice B) may be considered if increasing humidity alone is insufficient. Performing deep suctioning (Choice D) should be reserved for when other measures like increasing humidity have been ineffective.

2. One day after abdominal surgery, an obese client complains of pain and heaviness in the right calf. What action should the nurse implement?

Correct answer: A

Rationale: The correct action for the nurse to implement is to observe for unilateral swelling. Unilateral swelling could indicate a deep vein thrombosis (DVT), which is a serious complication that requires immediate assessment. Administering pain medication or applying warm compress may not address the underlying cause of the symptoms. Notifying the healthcare provider should be done after assessing and identifying the issue of unilateral swelling.

3. When obtaining a rectal temperature with an electronic thermometer, which action is most important for the nurse to perform?

Correct answer: A

Rationale: When obtaining a rectal temperature with an electronic thermometer, holding the thermometer in place is crucial. This action ensures accurate temperature measurement and prevents injury to the client. Option B, placing a disposable pad under the buttocks, is not the most important action; it may enhance comfort but does not impact the accuracy of the temperature reading. Option C, instructing the client to breathe deeply, is irrelevant to obtaining a rectal temperature. Option D, returning the probe to the charger, is an incorrect action after temperature measurement.

4. The healthcare provider is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which clinical finding is most concerning?

Correct answer: B

Rationale: In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, elevated blood pressure is the most concerning finding. Elevated blood pressure can indicate worsening hypertension, which requires immediate intervention to prevent further damage to the kidneys and other organs. Increased fatigue (choice A) is a common symptom in CKD but may not be as acutely concerning as elevated blood pressure. Elevated hemoglobin (choice C) can be an expected outcome of erythropoietin therapy and is not necessarily concerning. Low urine output (choice D) is important to monitor in CKD but may not be as immediately concerning as elevated blood pressure in this context.

5. After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement?

Correct answer: D

Rationale: The correct action for the nurse to implement after a client with hepatic encephalopathy has loose stools following lactulose administration is to monitor the client's mental status. Lactulose is given to lower serum ammonia levels in hepatic encephalopathy, and loose stools can be an expected side effect of its use. Monitoring mental status is crucial because changes in mental status, such as confusion or altered level of consciousness, are key indicators of hepatic encephalopathy worsening. Sending a stool specimen to the lab would not be the priority in this situation as loose stools are a known effect of lactulose. Measuring abdominal girth is more relevant for conditions like ascites, not loose stools. Encouraging increased fiber in the diet may be beneficial for constipation but is not the immediate action needed when loose stools occur after lactulose administration.

Similar Questions

A client with chronic heart failure is admitted with shortness of breath and a new onset of confusion. Which intervention should the nurse implement first?
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first?
The nurse is preparing to administer an IV dose of ciprofloxacin to a client with a urinary tract infection. Which client data requires the most immediate intervention by the nurse?
A client with diabetes mellitus is admitted with a blood glucose level of 640 mg/dl and is unresponsive. Which intervention should the nurse implement first?
A client with a history of coronary artery disease (CAD) is admitted with chest pain. Which diagnostic test should the nurse anticipate preparing the client for first?

Access More Features

HESI RN Basic
$69.99/ 30 days

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

HESI RN Premium
$149.99/ 90 days

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

Other Courses