a confused older client with alzheimers disease becomes incontinent of urine when attempting to find the bathroom which action should the nurse implem
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HESI RN

HESI RN Exit Exam 2024 Quizlet

1. A confused, older client with Alzheimer's disease becomes incontinent of urine when attempting to find the bathroom. Which action should the nurse implement?

Correct answer: A

Rationale: The correct action for the nurse to implement is to assist the client to a bedside commode every two hours. This approach, known as scheduled toileting, is essential in managing incontinence in clients with cognitive impairments like Alzheimer's disease. By providing regular assistance to the client to use the commode, the nurse can help maintain continence and reduce accidents. Inserting an indwelling catheter (Choice B) should be avoided if possible to prevent the risk of urinary tract infections. Using adult diapers (Choice C) should be considered a last resort and not the initial intervention. Restricting fluids in the evening (Choice D) is not appropriate as it may lead to dehydration and other complications.

2. A client with cirrhosis is admitted with jaundice and ascites. Which laboratory value requires immediate intervention?

Correct answer: C

Rationale: A serum ammonia level of 80 mcg/dL is most concerning in a client with cirrhosis as it may indicate hepatic encephalopathy, requiring immediate intervention. High serum ammonia levels can lead to altered mental status, confusion, and even coma. Serum albumin (choice A) is often decreased in cirrhosis but does not require immediate intervention. Serum bilirubin (choice B) elevation is expected in cirrhosis and may not require immediate intervention unless very high. Serum sodium (choice D) within the given range is generally acceptable and does not require immediate intervention.

3. 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.

4. An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The nurse notices the client has more energy and is giving her belongings away. Which intervention is best for the nurse to implement?

Correct answer: B

Rationale: The correct intervention is to ask the client if she has had any recent thoughts of harming herself because increased energy and giving away belongings can be signs of suicidal ideation. Choice A is incorrect as it does not address the potential risk of self-harm. Choice C is incorrect because reassurance about medication effectiveness may not be appropriate in this situation. Choice D is incorrect as it dismisses the client's current behavior without addressing the underlying concern of potential self-harm.

5. A client with a postoperative wound that eviscerated yesterday has an elevated temperature. What is the most important intervention for the nurse to implement?

Correct answer: B

Rationale: Obtaining a wound swab for culture and sensitivity is the most important intervention in this situation. It helps identify the presence of infection in the postoperative wound that could be causing the elevated temperature. By obtaining a wound swab, healthcare providers can determine the appropriate treatment needed to address any infection. Initiating contact isolation (Choice A) may be necessary in certain situations but is not the priority in this case. Assessing temperature (Choice C) is important but does not directly address the underlying cause of the elevated temperature. Using alcohol-based solutions for hand hygiene (Choice D) is a standard practice for infection control but is not the most crucial intervention in this scenario.

Similar Questions

A male client is admitted with a bowel obstruction and intractable vomiting for the last several hours despite the use of antiemetics. Which intervention should the nurse implement first?
An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to establish rapport and accomplish this therapeutic goal?
A client with urticaria due to environmental allergies is taking diphenhydramine (Benadryl). Which complaint should the nurse identify as a side effect of this OTC medication?
A client with chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which intervention should the nurse implement first?
A client with cirrhosis is admitted with jaundice and ascites. Which intervention should the nurse implement first?

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