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
Logo

Nursing Elites

HESI LPN

Adult Health Exam 1 Chamberlain

1. 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.

2. How should the nurse respond to an older male client who states that his religion does not permit him to bathe daily?

Correct answer: C

Rationale: The correct response is to offer the client several choices of times to bathe during the day. This approach respects the client's religious beliefs while ensuring that hygienic practices are still maintained. By providing options, the nurse can work together with the client to find a solution that aligns with both his beliefs and his health needs. Choice A is incorrect because solely reviewing the importance of hygiene may not address the client's specific religious concerns. Choice B is inappropriate as it disregards the client's beliefs and autonomy. Choice D is not the best approach as it may come off as confrontational or dismissive of the client's beliefs, rather than working collaboratively to find a suitable solution.

3. Which nonfood item is the most common cause of respiratory arrest in young children?

Correct answer: D

Rationale: The correct answer is D, Latex balloons. Latex balloons can pose a significant choking hazard to young children if inhaled, potentially leading to respiratory arrest. Broken rattles, buttons, and pacifiers are not typically known to cause respiratory arrest in young children. While these items can present choking hazards as well, the most common cause of respiratory arrest among young children is due to inhaling latex balloons.

4. A client with a history of atrial fibrillation is prescribed warfarin. Which lab value should the nurse monitor to assess the effectiveness of this medication?

Correct answer: D

Rationale: The correct answer is D, INR (International Normalized Ratio). The INR is used to monitor the effectiveness of warfarin therapy. Warfarin is an anticoagulant medication commonly prescribed for conditions like atrial fibrillation. Monitoring the INR helps healthcare providers ensure that the blood is clotting within a therapeutic range. Hemoglobin (Choice A), white blood cell count (Choice B), and platelet count (Choice C) are not directly related to monitoring the effectiveness of warfarin therapy in this context.

5. 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.

Similar Questions

After placing a client at 26-weeks gestation in the lithotomy position, the client complains of dizziness and becomes pale and diaphoretic. What action should the nurse implement?
The nurse is caring for a 75-year-old male client who is beginning to form a decubitus ulcer at the coccyx. Which intervention will be most helpful in preventing further development of the decubitus ulcer?
What is the homeostatic cellular transport mechanism that moves water from a hypotonic to a hypertonic fluid space?
A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed oxygen therapy at 2 liters per minute via nasal cannula. What is the most important instruction the nurse should provide?
A postoperative client complains of sudden shortness of breath. What should the nurse do first?

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