the nurse is assessing a client who has just undergone a thoracentesis which finding should be reported to the healthcare provider immediately
Logo

Nursing Elites

HESI LPN

Adult Health 2 Exam 1

1. The healthcare provider is assessing a client who has just undergone a thoracentesis. Which finding should be reported immediately?

Correct answer: D

Rationale: Shortness of breath should be reported immediately as it may indicate a pneumothorax, a potential complication of thoracentesis. Diminished breath sounds on the affected side, pain at the procedure site, and blood-tinged sputum are common findings post-thoracentesis and do not necessarily indicate immediate complications like a pneumothorax.

2. A client with chronic obstructive pulmonary disease (COPD) is struggling to breathe. What should the nurse do first?

Correct answer: D

Rationale: The correct first action for a nurse when a client with COPD is struggling to breathe is to assess the client's oxygen saturation and breath sounds. This initial assessment is crucial in determining the severity of the client's condition and the appropriate intervention. Increasing the oxygen flow rate without proper assessment can potentially be harmful, as COPD clients have a risk of retaining carbon dioxide. Encouraging pursed-lip breathing can be beneficial but should come after assessing the client's current status. Emergency intubation is a drastic measure and should only be considered after a comprehensive assessment indicates the need for it.

3. A client with a diagnosis of pneumonia is experiencing difficulty expectorating thick secretions. What intervention should the nurse implement to assist the client?

Correct answer: B

Rationale: Encouraging increased fluid intake is the appropriate intervention to assist the client with pneumonia who is having difficulty expectorating thick secretions. Adequate hydration helps to thin the secretions, making them easier to cough up. Administering antibiotics (Choice A) is important for treating the infection itself but does not directly address the thick secretions. Chest physiotherapy (Choice C) may be beneficial in some cases but is not the initial intervention for thick secretions. Providing humidified oxygen (Choice D) can help with oxygenation but does not directly address the problem of thick secretions.

4. 4 hours after administration of 20U of regular insulin, the client becomes shaky and diaphoretic. What action should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take when a client becomes shaky and diaphoretic after insulin administration, indicating hypoglycemia, is to provide the client with carbohydrates like crackers and milk. Carbohydrates help raise blood glucose levels quickly. Encouraging the client to eat crackers and milk (Choice A) is the appropriate immediate action to address the hypoglycemia. Administering more insulin (Choice B) would worsen hypoglycemia, and recording the reaction (Choice D) is important but not the immediate action needed to treat the hypoglycemia.

5. During a routine prenatal visit, a nurse measures a client’s fundal height. The client is 26 weeks pregnant. What should the fundal height be?

Correct answer: B

Rationale: The correct answer is B: Between 24 to 28 cm. Fundal height corresponds to the weeks of gestation, so at 26 weeks of pregnancy, the fundal height should range between 24 to 28 cm. This measurement is a quick way to assess fetal growth and amniotic fluid volume. Choice A is incorrect because fundal height may vary and not always match the exact weeks of pregnancy. Choice C, measuring above the umbilicus by two finger widths, is not a standard method for fundal height measurement. Choice D, below the xiphoid process, is too high and not relevant for assessing fundal height during pregnancy.

Similar Questions

A client with a severe headache is being assessed by a nurse. What should the nurse do first?
Following an open reduction of the tibia, the nurse notes fresh bleeding on the client's cast. What intervention should the nurse implement?
An elderly client is concerned about constipation during a flight. What should the nurse recommend?
A client is prescribed warfarin for the prevention of thromboembolism. What dietary instruction should the nurse provide?
A terminally ill male client and his family request hospice care after discharge. What aspect of care should the nurse indicate is the focus of hospice?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses