a male client with heart failure calls the clinic and reports that he cannot put his shoes on because they are too tight which additional information

HESI LPN

Medical Surgical Assignment Exam HESI Quizlet

1. A male client with heart failure calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain?

A. What time he took his medication?
B. Has his weight changed in the last several days?
C. Is he still able to tighten his belt buckle?
D. How many hours he slept last night?

Correct answer: B

Rationale: The correct answer is B: 'Has his weight changed in the last several days?' Sudden weight gain can indicate fluid retention, which is a common symptom of worsening heart failure. The inability to put on tight shoes can be due to fluid retention leading to swelling in the feet and ankles. Choices A, C, and D do not directly address the potential fluid retention issue and are less relevant in this scenario.

2. Which finding should the nurse report immediately for a client receiving a blood transfusion?

A. Mild itching and rash
B. Temperature increase of 1.5°F (0.8°C)
C. Heart rate increase of 10 beats per minute
D. Slight headache

Correct answer: B

Rationale: A temperature increase of 1.5°F (0.8°C) during a blood transfusion is a significant finding that can indicate a transfusion reaction, such as a febrile non-hemolytic reaction, which can progress to more severe reactions. It is crucial to report this immediately to the healthcare provider for further evaluation and intervention. Mild itching and rash (choice A) are common minor reactions to blood transfusions and can be managed appropriately without immediate concern. An increase in heart rate by 10 beats per minute (choice C) is within an acceptable range and may be a normal compensatory response to the transfusion. A slight headache (choice D) is a common complaint and is not typically associated with severe transfusion reactions; thus, it does not require immediate reporting compared to the temperature increase.

3. An adult client is admitted with AIDS and oral candidiasis manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide the UAP?

A. Assist with personal care, but leave oral care for the nurse to complete.
B. Provide a soft bristle brush for the client to use during oral care.
C. Use alcohol-based mouthwash to clean the ulcers.
D. Apply an antifungal cream to the mouth ulcers.

Correct answer: B

Rationale: The correct answer is B: 'Provide a soft bristle brush for the client to use during oral care.' Providing a soft bristle brush helps reduce trauma to the oral mucosa and assists in oral care. Choice A is incorrect because oral care can be safely delegated to UAPs. Choice C is wrong as alcohol-based mouthwash can further irritate the ulcers. Choice D is incorrect as applying an antifungal cream directly to the mouth ulcers is not the standard treatment for oral candidiasis.

4. What is a causative factor of Hirschsprung disease?

A. Frequent evacuation of solids, liquid, and gases
B. Excessive peristaltic movement
C. The absence of parasympathetic ganglion cells in a portion of the colon
D. One portion of the bowel telescoping into another

Correct answer: C

Rationale: The correct answer is C: The absence of parasympathetic ganglion cells in a portion of the colon is a causative factor of Hirschsprung disease. This absence leads to the inability of the affected segment of the colon to relax, causing a functional obstruction. Choices A, B, and D are incorrect. Frequent evacuation of solids, liquid, and gases, excessive peristaltic movement, and one portion of the bowel telescoping into another are not causative factors of Hirschsprung disease.

5. What is the major criterion for diagnosing cognitive impairment in a child?

A. An IQ of 75 or less
B. Subaverage functioning
C. An IQ of 70 or less
D. Onset before 18

Correct answer: C

Rationale: The correct criterion for diagnosing cognitive impairment in a child is having an IQ of 70 or less. This range is typically used to define cognitive impairment in children. Choice A ('An IQ of 75 or less') is incorrect as the threshold is generally set at 70 or below. Choice B ('Subaverage functioning') is vague and does not specifically address the IQ criterion. Choice D ('Onset before 18') is unrelated to the primary criterion of IQ level used in diagnosing cognitive impairment in children.