the client diagnosed with a right fractured femur has skeletal traction applied to the right femur which interventions should the nurse implement

HESI RN

HESI RN CAT Exit Exam

1. The client diagnosed with a right fractured femur has skeletal traction applied to the right femur. Which interventions should the nurse implement?

A. Perform passive range of motion to the right leg
B. Remove skeletal weights every shift to assess right leg
C. Turn frequently from prone to supine positions
D. Maintain skeletal pin sites and assess for signs of infection

Correct answer: D

Rationale: Maintaining skeletal pin sites and assessing for infection are critical in skeletal traction care.

2. A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal discharge as having a 'cottage cheese' appearance. Which prescription should the nurse implement first?

A. Cleanse the perineum with warm soapy water 3 times per day
B. Instill the first dose of nystatin (Mycostatin) vaginally per applicator
C. Perform a glucose measurement using a capillary blood sample
D. Obtain a blood specimen for sexually transmitted diseases (STDs)

Correct answer: B

Rationale: The correct answer is to instill the first dose of nystatin vaginally per applicator. Nystatin is an antifungal medication used to treat yeast infections, which are characterized by 'cottage cheese' discharge. Cleansing the perineum with warm soapy water may help with hygiene but does not address the underlying infection. Performing a glucose measurement is not relevant to the diagnosis of a vaginal infection. Obtaining a blood specimen for STDs is not the priority in this scenario as the symptoms described are indicative of a yeast infection.

3. An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned and oxygen provided, but the late decelerations continue to occur with each contraction. What action should the nurse take first?

A. Prepare for immediate cesarean birth
B. Turn off the oxytocin (Pitocin) infusion
C. Notify the anesthesiologist that the epidural infusion needs to be disconnected
D. Apply an internal fetal monitoring device and continue to monitor carefully

Correct answer: B

Rationale: In the scenario described, the presence of late decelerations during contractions indicates fetal compromise. To address this, the nurse's initial action should be to turn off the oxytocin (Pitocin) infusion. Oxytocin can contribute to uteroplacental insufficiency, leading to late decelerations. This intervention aims to improve fetal oxygenation and prevent further stress on the fetus. Immediate cesarean birth is not the first-line action unless other interventions fail. Notifying the anesthesiologist about disconnecting the epidural infusion is not the priority in this situation. Applying an internal fetal monitoring device is invasive and not the immediate step needed when late decelerations are present.

4. Nurses working in labor and delivery are demanding a change in policy because they believe they are required to float more often than nurses on other units. However, floating to labor and delivery is not reciprocated because other nurses are not competent to provide highly specialized obstetrical skills. What action is best for the nurse-manager to implement?

A. Require cross-training for obstetrics for other nurses
B. Propose a method for self-staffing labor and delivery
C. Remind nurses that floating is an administrative policy
D. Encourage nurses to share their feelings with administration

Correct answer: B

Rationale: The best action for the nurse-manager to implement is to propose a method for self-staffing labor and delivery. This approach allows nurses to manage their schedules, ensuring a fair balance of workloads. Requiring cross-training for obstetrics for other nurses (Choice A) may not be feasible or necessary for all units. Reminding nurses that floating is an administrative policy (Choice C) does not address the underlying issue of workload balance. Encouraging nurses to share their feelings with administration (Choice D) may not lead to a concrete solution for the unequal floating concerns.

5. The nurse is assessing on the first postoperative day following thyroid surgery. Which laboratory value is most important for the nurse to monitor?

A. Calcium
B. Sodium
C. Chloride
D. Potassium

Correct answer: A

Rationale: Corrected Rationale: Monitoring calcium levels is crucial post-thyroid surgery to detect hypocalcemia, a common complication due to injury or removal of the parathyroid glands. Monitoring sodium, chloride, or potassium levels is not as vital in the immediate post-thyroid surgery period.