after a spider bite on the lower extremity a client is admitted to treat an infection that is spreading up the leg which admission assessment findings
Logo

Nursing Elites

HESI RN

HESI RN Exit Exam 2024 Quizlet Capstone

1. After a spider bite on the lower extremity, a client is admitted to treat an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider?

Correct answer: C

Rationale: All of the above findings should be reported to the healthcare provider for prompt evaluation and treatment. Swollen lymph nodes in the groin indicate regional lymphatic involvement, a core body temperature of 100.5°F suggests a mild fever response, and an elevated white blood cell count indicates an ongoing infection process. These findings collectively point towards the spread of infection and require immediate attention to prevent further complications.

2. An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take?

Correct answer: B

Rationale: An S3 heart sound is often a normal finding in pregnant women due to increased blood volume and cardiac output. The nurse should document the finding as part of the routine assessment unless accompanied by other abnormal symptoms. Performing a 12-lead electrocardiogram (Choice A) is unnecessary for a normal S3 heart sound in pregnancy. Notifying the healthcare provider immediately (Choice C) is premature and may lead to unnecessary interventions. Assessing for signs of heart failure (Choice D) is not indicated as an isolated S3 heart sound is typically benign in pregnancy.

3. The nurse assesses a client’s wound. What type of wound requires immediate intervention by the nurse?

Correct answer: A

Rationale: Lacerations, especially deep ones, are prone to bacterial contamination and may require immediate intervention to prevent infection. Abrasions, contusions, and ulcerations are not as likely to lead to immediate serious complications like infections as lacerations.

4. A client receiving IV heparin reports abdominal pain and tarry stools. What is the nurse's priority action?

Correct answer: A

Rationale: The correct answer is to prepare to administer protamine sulfate. Abdominal pain and tarry stools are indicative of gastrointestinal bleeding, a serious side effect of heparin therapy. Protamine sulfate is the antidote for heparin and is used to reverse its effects in cases of bleeding. Continuing the heparin infusion (Choice B) is not appropriate when the client is experiencing signs of bleeding. Monitoring vital signs and assessing abdominal pain (Choice C) is important but not the priority when immediate action is required to address potential bleeding. Administering morphine sulfate (Choice D) is not the priority in this situation; addressing the underlying cause of bleeding takes precedence.

5. The healthcare provider prescribes a sedative for a client with severe hypothyroidism. What is the best action for the nurse to take?

Correct answer: A

Rationale: The correct answer is to affirm the nurse's plan to review the prescription with the provider. Sedatives can worsen symptoms of hypothyroidism, so it is crucial to ensure the safety of the prescribed medication. Administering the sedative without further consultation could lead to adverse effects. Simply advising the nurse to administer the medication without addressing the need for review is not the best course of action. Offering to administer the medication without proper assessment or consulting the provider is not appropriate and could potentially harm the client.

Similar Questions

The nurse is assessing a client 2 hours postoperatively following an appendectomy. The nurse should intervene for which abnormal finding?
Why is it important for the healthcare provider to monitor blood pressure in clients receiving antipsychotic drugs?
A client has suspected compartment syndrome of the right lower leg. What is the nurse’s priority intervention?
A male client admitted for schizophrenia is noted to be diaphoretic and pacing the hallway. What is the most important intervention?
Which of these clients, all in the terminal stage of cancer, is least appropriate to suggest the use of patient-controlled analgesia (PCA) with a pump?

Access More Features

HESI RN Basic
$69.99/ 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