a nurse is caring for a client scheduled for abdominal surgery the client reports being worriewhich of the following actions should the nurse take
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Nursing Elites

HESI LPN

HESI Fundamentals Test Bank

1. A client scheduled for abdominal surgery reports being worried. Which of the following actions should the nurse take?

Correct answer: A

Rationale: Offering relaxation techniques addresses the client's immediate concern by providing a proactive approach to managing anxiety. It shows empathy and offers a practical solution. Requesting a social worker for meditation (Choice B) may not be the most direct response to the client's immediate worry. Attempting biofeedback (Choice C) may not be suitable without the client's interest or consent. Telling the client to think of something else (Choice D) dismisses the client's feelings and does not provide constructive support.

2. The healthcare professional is preparing to administer an intramuscular injection to an adult client. Which site is most appropriate for the LPN/LVN to use?

Correct answer: B

Rationale: The ventrogluteal site is the most appropriate and safest site for administering an intramuscular injection to an adult client. It is preferred due to its thick muscle mass and fewer major blood vessels and nerves in the area, reducing the risk of injury or complications. The deltoid muscle is commonly used for vaccines and small-volume injections but may not be suitable for larger volumes. The dorsogluteal site has fallen out of favor due to the risk of injury to the sciatic nerve and other underlying structures. The rectus femoris site is not typically used for intramuscular injections in adults.

3. The client is post-operative following abdominal surgery. Which of the following assessment findings would require immediate intervention?

Correct answer: B

Rationale: A saturated abdominal dressing is a critical finding that may indicate active bleeding or wound complications. Immediate intervention is necessary to prevent further complications, such as hypovolemic shock or infection. Absent bowel sounds, though abnormal, are a common post-operative finding and do not require immediate intervention. Pain level of 8/10 can be managed effectively with appropriate pain control measures and does not indicate an urgent issue. A temperature of 100.4°F is slightly elevated but may be a normal post-operative response to surgery and does not typically require immediate intervention unless accompanied by other concerning signs or symptoms.

4. When should discharge planning be initiated for a client experiencing an exacerbation of heart failure?

Correct answer: A

Rationale: Discharge planning should begin during the admission process for a client experiencing an exacerbation of heart failure. Initiating discharge planning early ensures timely and effective care transitions, which are crucial for managing the client's condition and preventing readmissions. Waiting until after the client stabilizes (choice B) could lead to delays in arranging necessary follow-up care and support services. Similarly, waiting for the client to request discharge planning (choice C) may result in missed opportunities for comprehensive care coordination. Planning at the time of discharge (choice D) is too late, as early intervention is key to promoting the client's well-being and recovery in the long term.

5. A client with a history of diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What is the most important action for the nurse to take?

Correct answer: A

Rationale: The most critical action for the nurse to take when a client with diabetes mellitus presents with symptoms of hyperglycemia such as polyuria, polydipsia, and polyphagia is to monitor the client's blood glucose level. This action helps in assessing the client's current glycemic status and guides further interventions. Encouraging increased fluid intake (Choice B) may be beneficial in managing dehydration caused by polyuria, but it does not address the underlying cause of hyperglycemia. Administering insulin as prescribed (Choice C) may be necessary based on the blood glucose monitoring results, but monitoring should precede any medication administration. Assessing the client's urine output (Choice D) is important but does not directly address the primary concern of evaluating and managing hyperglycemia in a client with diabetes.

Similar Questions

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A client who is 3 days post-op following a cholecystectomy has yellow and thick drainage on the dressing. The nurse suspects a wound infection. The nurse identifies this type of drainage as:
A postoperative client has been diagnosed with paralytic ileus. When performing auscultation of the client’s abdomen, the nurse expects the bowel sounds to be:
By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?

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