a nurse is caring for a client who reports pain after medication the client continues to express discomfort what is the next best step
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Nursing Elites

HESI LPN

Adult Health Exam 1

1. A client reports pain after medication administration. What is the next best step for the nurse?

Correct answer: A

Rationale: The correct answer is to reassess the client’s pain. Reassessment is essential to evaluate the effectiveness of the initial intervention. By reassessing, the nurse can determine if the current pain management plan is adequate or if further interventions are required. Increasing the pain medication dose without reassessment can lead to overmedication and potential adverse effects. Applying a cold compress may not address the underlying cause of the pain and should be based on a proper assessment. Contacting the healthcare provider should be considered if the reassessment indicates a need for further evaluation or intervention beyond the nurse's scope of practice.

2. A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu items should the nurse suggest? (Select all that apply.)

Correct answer: A

Rationale: A high-fiber diet is beneficial for managing hemorrhoids as it helps maintain bowel regularity. Raisin bran muffins are a good choice for breakfast as they are high in fiber. Oatmeal is also a high-fiber option that aids digestion and prevents constipation. Raspberries are rich in fiber and contribute to a high-fiber diet. Scrambled eggs, on the other hand, are not high in fiber and do not provide the necessary fiber content needed for managing hemorrhoids.

3. A client with a cast complains of numbness and tingling in the affected limb. What should the nurse do first?

Correct answer: A

Rationale: The correct first action for a client with a cast experiencing numbness and tingling in the affected limb is to check for tightness of the cast. Numbness and tingling can indicate compromised circulation, and a tight cast may be causing this. Checking the cast for tightness is essential to ensure it is not impeding circulation. Elevating the limb, applying ice, or notifying the physician can be subsequent actions depending on the assessment findings after checking the cast. Elevating the limb might help improve circulation, applying ice is not indicated for numbness and tingling, and notifying the physician can be done if the issue persists after addressing the immediate concern of cast tightness.

4. A client with a diagnosis of diabetes mellitus is experiencing symptoms of hypoglycemia. What is the nurse's priority intervention?

Correct answer: D

Rationale: The correct answer is to give 15 grams of a fast-acting carbohydrate as the priority intervention in a client experiencing hypoglycemia. This helps quickly raise the blood glucose level. Administering glucagon intramuscularly (Choice A) is typically reserved for severe hypoglycemia where the client is unable to take oral carbohydrates. Providing a complex carbohydrate snack (Choice B) is not the priority in an acute hypoglycemic episode where immediate action is needed. Administering 50% dextrose intravenously (Choice C) is more invasive and usually reserved for cases where the client is unable to take anything by mouth.

5. After a 26-year-old gravida 4, para 0 experienced a spontaneous abortion at 9 weeks gestation, how should the nurse intervene after observing the client crying softly one hour post dilation and curettage (D&C)?

Correct answer: C

Rationale: After a traumatic experience like a spontaneous abortion, it is crucial for the nurse to provide emotional support. Expressing sorrow for the client's grief and offering to sit with her demonstrates empathy and allows the client to process her emotions. Options A and B focus on future possibilities and medical interventions, which may not be immediately appropriate. Option D, while important for monitoring the client's physical status, does not address the client's emotional needs at that moment.

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