the nurse is assessing a client who has just undergone a thoracentesis which finding should be reported to the healthcare provider immediately
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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. The nurse is caring for a client with increased intracranial pressure (ICP). Which position should the nurse avoid?

Correct answer: B

Rationale: The correct answer is B: Positioning the client in the prone position. Placing the client in the prone position should be avoided in a client with increased intracranial pressure (ICP) as it can further raise ICP. The prone position can hinder venous return and increase pressure within the cranial vault, potentially worsening the client's condition. Keeping the head of the bed elevated at 30 degrees helps promote venous drainage and reduce ICP. Placing the client in a lateral recumbent position can also assist in reducing ICP by optimizing cerebral perfusion. Elevating the client's legs can help improve venous return and maintain adequate cerebral blood flow, making it a suitable positioning intervention for managing increased ICP.

3. The client with hypertension is being taught about lifestyle changes. Which recommendation is most important to include?

Correct answer: B

Rationale: Engaging in regular physical activity is crucial for managing hypertension as it helps lower blood pressure. Regular exercise can improve heart health, increase circulation, and contribute to overall well-being, all of which are beneficial for individuals with hypertension. Choice A, increasing sodium intake, is incorrect as reducing sodium is recommended for hypertension to help lower blood pressure. Choice C, consuming a diet high in saturated fats, is incorrect as a diet high in saturated fats can negatively impact blood pressure and cardiovascular health. Choice D, limiting fluid intake, is incorrect as maintaining adequate hydration is important for overall health and not directly related to hypertension management.

4. The nurse is caring for a client who is scheduled for surgery in the morning. The client reports drinking a glass of water at midnight. What should the nurse do?

Correct answer: A

Rationale: The correct answer is to notify the anesthesiologist. When a client reports drinking water close to the time of surgery, it is important to inform the anesthesiologist as it can impact the administration of anesthesia. The anesthesiologist needs this information to make decisions regarding anesthesia administration. Documenting the intake in the medical record is important for documentation purposes, but the immediate action needed is to inform the anesthesiologist. Canceling the surgery is not necessary based solely on the intake of water; the anesthesiologist will determine the appropriate course of action. Instructing the client to fast until the surgery may not be appropriate without consulting the anesthesiologist first, as the situation needs to be assessed by the anesthesia team.

5. The nurse is assessing an older resident with a history of Benign Prostatic Hypertrophy and identifies a distended bladder. What should the nurse do?

Correct answer: D

Rationale: Prompt and appropriate management of urinary retention prevents complications like infection and bladder damage.

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