the nurse is assessing a client who has just returned from surgery which of these findings requires the most immediate attention
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Nursing Elites

HESI RN

HESI Nutrition Proctored Exam Quizlet

1. The healthcare provider is assessing a client who has just returned from surgery. Which of these findings requires the most immediate attention?

Correct answer: C

Rationale: A temperature of 99.5 degrees Fahrenheit is slightly elevated but not immediately critical. In a postoperative patient, an elevated temperature could indicate an infection, which requires prompt attention to prevent complications. The respiratory rate, blood pressure, and heart rate within normal ranges are important to monitor but do not indicate an immediate need for intervention as an elevated temperature does.

2. The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective and must be reported by the nurse immediately to the healthcare provider?

Correct answer: B

Rationale: A high fever, such as 103 degrees Fahrenheit (39.5 degrees Celsius), in a client with infective endocarditis indicates that the infection may not be responding to the antibiotics and requires immediate medical evaluation. Nausea and vomiting, diffuse macular rash, and muscle tenderness are not typically associated with the ineffectiveness of antibiotic therapy in infective endocarditis.

3. Which of these findings would the nurse most closely associate with anemia in a 10-month-old infant?

Correct answer: B

Rationale: The correct answer is B. Pale mucosa of the eyelids and lips is a classic sign of anemia in infants, indicating a lack of sufficient red blood cells. This finding is due to decreased hemoglobin levels, which causes reduced oxygen delivery to tissues. Choices A, C, and D are less specific to anemia in infants. While a hemoglobin level of 12 g/dL may be within the normal range for a 10-month-old infant, the presence of pale mucosa is a more indicative sign of anemia.

4. A client with diabetes mellitus has a blood glucose level of 350 mg/dL. Which of these actions should the nurse take first?

Correct answer: A

Rationale: Administering insulin as ordered is the priority action when a client with diabetes mellitus has a blood glucose level of 350 mg/dL. Insulin helps to lower the high blood glucose level and prevent complications such as diabetic ketoacidosis. Encouraging the client to drink fluids may be beneficial but does not address the immediate need to lower the blood glucose level. Notifying the healthcare provider and rechecking the blood glucose level can be important steps but should come after administering insulin to address the high glucose level promptly.

5. An 85-year-old client complains of generalized muscle aches and pains. What should be the nurse's first action?

Correct answer: A

Rationale: The correct answer is to assess the severity and location of the pain. This is crucial because understanding the nature of the pain will guide the nurse in developing an appropriate pain management plan. Choice B is incorrect because administering analgesics should come after assessing the pain to ensure the right medication is given. Choice C is incorrect because dismissing the pain as a normal part of aging without proper assessment could overlook underlying issues. Choice D is incorrect as increasing activity without understanding the cause of pain may exacerbate the client's condition.

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