the nurse is assessing a client with cirrhosis who has developed ascites what is the most important intervention to include in the care plan
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Nursing Elites

HESI LPN

Adult Health 2 Exam 1

1. The nurse is assessing a client with cirrhosis who has developed ascites. What is the most important intervention to include in the care plan?

Correct answer: D

Rationale: The correct answer is to administer diuretics as prescribed. Diuretics are often prescribed to help manage fluid accumulation in ascites, which is a common complication of cirrhosis. Restricting sodium intake (Choice A) is essential in managing ascites, but administering diuretics takes precedence in the care plan. Encouraging high-protein meals (Choice B) and increasing fluid intake (Choice C) are not the primary interventions for managing ascites in cirrhosis.

2. A grand multiparous client had a precipitous delivery in the emergency room 6 hours ago. The client was given oxytocin intramuscularly after birth. The nurse examines the client and observes the pad under her buttocks is full of blood. Which action should the nurse take first?

Correct answer: B

Rationale: Massaging the fundus and expressing clots helps contract the uterus and reduce postpartum hemorrhage.

3. The nurse is providing care for a client with a draining postoperative wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which is the most important action for the nurse to take?

Correct answer: D

Rationale: Administering prescribed antibiotics is crucial in treating MRSA infections. MRSA is a type of bacteria that is resistant to many antibiotics, including methicillin. Therefore, prompt administration of the appropriate antibiotics is essential to target the MRSA infection effectively. Encouraging increased oral fluids (Choice A) and providing high-protein snacks (Choice B) may be beneficial for overall recovery but are not the most important actions in treating an MRSA infection. Changing the wound dressing (Choice C) is important for wound care but does not directly address the infection caused by MRSA.

4. A client with a chronic illness expresses frustration over their condition. What is the nurse's best response to support the client?

Correct answer: D

Rationale: The best response for the nurse to support a client expressing frustration over their chronic illness is to validate their feelings and listen to their concerns (Option D). This approach helps acknowledge the client's emotions, demonstrates empathy, and establishes a therapeutic relationship. By validating the client's feelings and actively listening to their concerns, the nurse offers a supportive environment for the client to express their frustrations. Choices A, B, and C are not the best responses in this situation. While joining a support group, discussing a cure, or focusing on positive aspects can be beneficial interventions, the immediate priority is to validate the client's feelings and provide a space for them to express their frustrations.

5. A client with a urinary tract infection is prescribed antibiotics. What should the nurse inform the client about antibiotic therapy?

Correct answer: D

Rationale: Completing the full course of antibiotics is crucial to fully eradicate the infection and prevent the development of antibiotic resistance. Informing the client about the importance of finishing the prescribed course helps in ensuring the effectiveness of the treatment and reduces the risk of recurrence. Choice A is incorrect because antibiotics do not generally interfere with oral contraceptive effectiveness. Choice B is incorrect because drowsiness is not a common side effect of antibiotics. Choice C is incorrect because while some antibiotics may need to be taken with meals, it is not a universal rule for all antibiotics.

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