the nurse is caring for a 4 year old 2 hours after tonsillectomy and adenoidectomy which of the following assessments must be reported immediately
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HESI Fundamentals Exam Test Bank

1. The nurse is caring for a 4-year-old 2 hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported immediately?

Correct answer: D

Rationale: Increased restlessness must be reported immediately as it may indicate bleeding or other complications post-tonsillectomy and adenoidectomy. This could be a sign of a developing issue that requires urgent intervention. Vomiting of dark emesis, complaints of throat pain, and an apical heart rate of 110 are important to monitor but do not indicate an immediate need for reporting as compared to the potential seriousness of increased restlessness in this scenario.

2. Before starting an intensive exercise program, what instruction is most important for the nurse to provide to the client?

Correct answer: A

Rationale: Before starting an intensive exercise program, it is crucial for the client to have a complete physical examination. This examination ensures that the client is physically fit to engage in such activities and helps in identifying any underlying health issues that could be exacerbated by the exercise regimen. Choice B is incorrect because it focuses on stress levels related to eating habits rather than the importance of a physical examination for safety. Choice C is incorrect as exercise and stress management classes can complement each other rather than being mutually exclusive. Choice D is incorrect as monitoring weight loss, while important, is not as critical as ensuring the client's physical readiness for the exercise program.

3. A nurse at an assisted living facility is preparing an in-service for residents about electrical safety. Which of the following instructions should the nurse include?

Correct answer: A

Rationale: The correct instruction for electrical safety is to avoid taping electrical cords to the floor. Taping cords can create tripping hazards, leading to falls and potential injuries. Choice B, cleaning electrical equipment before disconnection, is not directly related to electrical safety but rather to equipment maintenance. Choice C, covering exposed wires with tape before use, is incorrect as exposed wires should be properly insulated and repaired by a qualified professional. Choice D, disconnecting electrical equipment by grasping the plug, is unsafe and can lead to electrical shocks. It is always recommended to unplug devices by holding the plug itself, not by pulling the cord.

4. The healthcare provider is teaching a patient about contact lens care. Which instructions will the healthcare provider include in the teaching session?

Correct answer: B

Rationale: The correct answer is B. Washing and rinsing the lens storage case daily is essential to prevent contamination and infections. Choice A is incorrect as tap water should not be used to clean soft lenses due to the risk of introducing harmful microorganisms. Choice C is incorrect as the storage solution should not be reused for longer than recommended to maintain its effectiveness and prevent eye infections. Choice D is incorrect because lenses should be stored in a clean, disinfected case, not just in a cool, dry place, to avoid contamination.

5. The nurse is caring for a client with a nasogastric (NG) tube. Which action should the LPN/LVN take to maintain patency of the tube?

Correct answer: A

Rationale: The correct action to maintain patency of a nasogastric (NG) tube is to flush the tube with water before and after medication administration. Flushing helps prevent clogging and ensures that the tube remains clear for proper functioning. Securing the tube to the client's gown (Choice B) is important for stability but does not directly address tube patency. Checking the placement of the tube by auscultation (Choice C) is crucial for verifying correct placement but does not specifically relate to maintaining tube patency. Irrigating the tube with normal saline every shift (Choice D) is not a routine practice for maintaining tube patency and can lead to electrolyte imbalances.

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