a patient is admitted for hypovolemia associated with multiple draining wounds which assessment would be the most accurate way for the nurse to evalua
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Nursing Elites

HESI RN

Adult Health 1 HESI

1. A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?

Correct answer: B

Rationale: Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age and can be affected by various factors other than fluid balance. Presence of edema indicates excess fluid has moved into the interstitial space, which may not always be directly correlated with overall fluid balance. Hourly urine outputs, though important, do not provide a comprehensive picture of fluid balance as they do not consider fluid intake, insensible losses, or other sources of fluid loss.

2. A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion?

Correct answer: A

Rationale: The correct answer is A: Lung sounds. Hypertonic solutions like 3% NaCl can cause water retention, leading to fluid excess. Monitoring lung sounds is crucial as crackles may indicate pulmonary edema, a serious manifestation of fluid excess. While monitoring urinary output, peripheral pulses, and peripheral edema are also important when administering hypertonic solutions, they do not provide immediate clues to acute respiratory or cardiac decompensation like lung sounds.

3. The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L/min. To assess for skin damage related to the cannula, which areas should the nurse observe? (Select all that apply).

Correct answer: C

Rationale: The correct answer is C: 'Around the nostrils.' Constant pressure from the tubing may create skin damage to the areas of skin and bony prominences the nasal cannula will be resting on, including around the nostrils. Choice A, 'Tops of the ears,' is incorrect as the cannula does not rest on the ears. Choice B, 'Bridge of the nose,' is incorrect because the cannula typically rests under the nose. Choice D, 'Over the cheeks,' is also incorrect as the cannula does not typically rest on the cheeks.

4. A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first?

Correct answer: A

Rationale: The health care provider should be notified immediately. The patient has a history and manifestations consistent with hypermagnesemia. The nurse should check the chart for a recent serum magnesium level and make sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations. Dialysis should correct the high magnesium levels. The patient needs teaching about the risks of taking magnesium-containing antacids. Monitoring of potassium levels also is important for patients with renal failure, but the patient’s current symptoms are not consistent with hyperkalemia.

5. The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?

Correct answer: B

Rationale: The correct answer is B because using the push-pause method to flush the CVAD after giving medications helps remove debris from the CVAD lumen and decreases the risk for clotting. Choice A is incorrect because friction should be used when cleaning the CVAD insertion site to decrease infection risk. Choice C is incorrect because obtaining an order from the healthcare provider to change the CVAD dressing is not necessary; the dressing should be changed when damp, loose, or visibly soiled. Choice D is incorrect because the patient should face away from the CVAD during cap changes to minimize the risk of contamination.

Similar Questions

The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?
A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action?
A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?
IV potassium chloride (KCl) 60 mEq is prescribed for the treatment of a patient with severe hypokalemia. Which action should the nurse take?
Which task can the registered nurse (RN) caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?

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