a nurse checks a client who is on a volume cycled ventilator which finding indicates that the client may need suctioning
Logo

Nursing Elites

HESI RN

HESI Nutrition Practice Exam

1. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning?

Correct answer: D

Rationale: Restlessness is often a sign of respiratory distress or secretion build-up, indicating the need for suctioning. While drowsiness (choice A) can be a sign of hypoxia, it is not as immediate an indication for suctioning as restlessness. Complaint of nausea (choice B) and a pulse rate of 92 (choice C) are not directly related to the need for suctioning in a client on a volume-cycled ventilator.

2. During an excretory urogram, which observation made by the nurse indicates a complication?

Correct answer: B

Rationale: The observation of the client's entire body turning a bright red color during an excretory urogram indicates a severe reaction to the dye, which is a significant complication. This reaction is likely due to an allergic response and requires immediate medical attention. The other choices do not signify a severe complication: choice A could be a normal taste sensation related to the procedure, choice C may indicate a mild reaction, and choice D could be a common side effect of nausea without indicating a severe complication requiring immediate intervention.

3. A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure?

Correct answer: C

Rationale: Loss of pulse in the extremity can indicate an arterial blockage, requiring immediate medical evaluation. Increased blood pressure and heart rate are common physiological responses after cardiac catheterization and may not necessarily indicate a complication. Decreased urine output is more indicative of renal function and may not be directly related to complications from the procedure.

4. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?

Correct answer: D

Rationale: A serum potassium level of 6 mEq/L indicates hyperkalemia, which can be life-threatening and requires immediate intervention. Hyperkalemia can lead to dangerous cardiac arrhythmias and must be addressed promptly. The other options are not as urgent. A blood urea nitrogen level of 50 mg/dl may indicate kidney dysfunction but does not require immediate intervention. Hemoglobin of 10.3 g/dl may suggest anemia, which needs management but is not an immediate threat. A venous blood pH of 7.30 may indicate acidosis, which is concerning but not as acutely dangerous as hyperkalemia.

5. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?

Correct answer: D

Rationale: The correct answer is D: Altered patterns of urinary elimination related to nocturia. Nocturia increases the risk of falls in elderly clients due to frequent nighttime trips to the bathroom. Choice A is incorrect because while decreased vision can contribute to falls, nocturia poses a more direct risk. Choice B is incorrect as fatigue may affect mobility but is not as directly linked to falls as nocturia. Choice C is incorrect as impaired gas exchange is not typically associated with an increased risk of falls.

Similar Questions

A nurse is reinforcing teaching with a client who has constipation about a high-fiber diet. Which of the following foods should be included as sources of fiber? Select one that doesn't apply.
The nurse is caring for a client with a new diagnosis of diabetes mellitus. Which of these statements made by the client indicates a need for further teaching?
A client is receiving teaching about a high-fiber diet to manage constipation. Which statement indicates the best choice for a high-fiber diet?
While assessing several clients in a long-term health care facility, which client is at the highest risk for developing decubitus ulcers?
A client is lactose intolerant, and a nurse is reinforcing teaching. Which of the following statements should the nurse include?

Access More Features

HESI RN Basic
$89/ 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