a nurse is administering diazepam a benzodiazepine 10 mg iv push prn as prescribed to a client with alcohol withdrawal symptoms which actions should t
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HESI CAT Exam Test Bank

1. When administering diazepam, a benzodiazepine, 10 mg IV push PRN for a client with alcohol withdrawal symptoms, which actions should the nurse implement? (Select all that apply)

Correct answer: D

Rationale: When administering diazepam for a client with alcohol withdrawal symptoms, it is crucial to perform ongoing assessment of respiratory status. Diazepam can lead to respiratory depression, emphasizing the need for continuous monitoring to detect any signs of respiratory distress early. Protecting the medication from light exposure is a general guideline for some drugs but is not a specific concern for diazepam. Observing for bruising or bleeding is not directly associated with the administration of diazepam for alcohol withdrawal symptoms, making choices A and C incorrect.

2. In what order should the nurse perform the steps of a surgical hand scrub prior to entering the operating room?

Correct answer: B

Rationale: The correct order for performing a surgical hand scrub is to first scrape under the nails with a nail pick, then scrub the hands using a soapy brush, cleanse the arms, and finally rinse. This sequence ensures thorough cleaning and minimizes the risk of contamination. Choice A is incorrect because rinsing should be the final step, not the first. Choice C is incorrect as scrubbing the hands comes after scraping under the nails. Choice D is incorrect as cleansing the arms should follow hand scrubbing, not precede it.

3. The client with a mechanical valve replacement understands the discharge teaching when the client makes which statement?

Correct answer: A

Rationale: The correct answer is A. Clients with mechanical valve replacements need to take prophylactic antibiotics before dental procedures to prevent endocarditis. Choice B is incorrect because even with a new valve, heart medications may still be necessary to manage the condition. Choice C is incorrect because mechanical valves typically do not need replacement as frequently as within 10 years. Choice D is incorrect because hearing a clicking sound near the heart could indicate valve malfunction, not just the need to notify the healthcare provider.

4. The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. What action should the nurse implement immediately?

Correct answer: B

Rationale: The correct action for the nurse to implement immediately upon identifying clear fluid on the surgical dressing post-lumbar surgery is to test the fluid for glucose. Clear fluid could indicate cerebrospinal fluid (CSF) leakage, and testing for glucose can help confirm this. Changing the dressing using a compression bandage (Choice A) without further assessment could lead to complications. Documenting the findings (Choice C) is important but not as immediate as confirming the presence of CSF. Marking the drainage area with a pen and monitoring (Choice D) does not address the need for immediate confirmation of CSF leakage.

5. Following the evacuation of a subdural hematoma, an older adult develops an infection. The client is transferred to the neuro intensive care unit with a temperature of 101.8 F (39.3 C) axillary, pulse of 180 beats/minute, and a blood pressure of 90/60 mmHg. What is the priority intervention to include in this client’s plan of care?

Correct answer: C

Rationale: The priority intervention for the client in this scenario is to maintain intravenous (IV) access. Given the client's condition with infection, elevated temperature, tachycardia, and hypotension, it is crucial to ensure IV access for administering antibiotics, fluids, and other medications promptly. This can help manage the infection, stabilize hemodynamics, and support the client's hydration and medication needs. Checking neuro vital signs, although important, is secondary to addressing the immediate need for IV access. Keeping the suture line clean and dry is important for wound care but not the priority when dealing with a systemic infection and hemodynamic instability.

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