an adult has a coagulation time of 20 minutes the nurse should observe the client for which of the following
Logo

Nursing Elites

HESI RN

HESI Fundamentals Quizlet

1. An adult has a coagulation time of 20 minutes. The nurse should observe the client for which of the following?

Correct answer: B

Rationale: A coagulation time of 20 minutes is prolonged, suggesting a potential bleeding disorder. Ecchymotic areas, which are areas of bruising, are common signs of abnormal bleeding. Therefore, the nurse should observe the client for ecchymotic areas to monitor for potential bleeding issues. Blood clots are not typically associated with prolonged coagulation time but rather with excessive clotting. Jaundice is related to liver dysfunction, and infection is not directly linked to coagulation time.

2. A client with a diagnosis of renal failure is receiving hemodialysis. Which assessment finding should the nurse report to the healthcare provider immediately?

Correct answer: C

Rationale: A potassium level of 5.5 mEq/L (C) is elevated and concerning in a client with renal failure receiving hemodialysis, as it can lead to life-threatening cardiac arrhythmias. Monitoring blood pressure (A), weight gain (B), and weight loss (D) are essential in clients on hemodialysis, but an elevated potassium level poses an immediate risk that requires prompt intervention.

3. What intervention should the healthcare provider include in the plan of care for a client receiving treatment with an Unna's paste boot for leg ulcers due to chronic venous insufficiency?

Correct answer: A

Rationale: When an Unna's paste boot is applied for leg ulcers due to chronic venous insufficiency, it is crucial to check the capillary refill of the toes on the lower extremity to ensure adequate circulation. The Unna's paste boot can become rigid after drying, potentially affecting circulation distally. Monitoring capillary refill helps assess the perfusion status of the distal extremity and ensures that the treatment is not compromising circulation to the toes.

4. The nurse explains to an older adult male the procedure for collecting a 24-hour urine specimen for creatinine clearance. Which action is most important for the nurse to include in their care plan for the shift?

Correct answer: C

Rationale: To ensure accurate creatinine clearance results, it is crucial to collect all urine within the 24-hour period. The process should begin with discarding the first specimen and then collecting all subsequent urine in the designated 24-hour collection container. This ensures that the sample is complete and accurate for the creatinine clearance calculation.

5. A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best?

Correct answer: A

Rationale: The best action for the nurse is to determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. By incorporating familiar bedtime rituals that do not compromise the client's safety, the nurse can help the client fall asleep faster and improve the overall quality of care provided to the client.

Similar Questions

The nursing staff in the cardiovascular intensive care unit is creating a continuous quality improvement project on social media that addresses coronary artery disease (CAD). Which action should the nurse implement to protect client privacy?
A client who has been on bed rest for several days is at risk for developing deep vein thrombosis (DVT). Which intervention should the nurse include in the client's plan of care?
When assisting a client with right-sided hemiplegia to get into a wheelchair, how should the nurse position the wheelchair?
A client is receiving external radiation therapy for lung cancer. Which intervention is most important for the nurse to include in the client's plan of care?
The healthcare provider obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the healthcare provider implement first?

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