the nurse is caring for a client who is unable to void the plan of care establishes an objective for the client to ingest at least 1000 ml of fluid be
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Nursing Elites

HESI RN

Community Health HESI Quizlet

1. The client is unable to void, and the plan of care sets an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Which client response should the nurse document to indicate a successful outcome?

Correct answer: D

Rationale: The correct answer is D. Drinking 240 mL of fluid five times during the shift indicates a fluid intake of 1200 mL, which exceeds the minimum objective of at least 1000 mL. The client meeting or exceeding the fluid intake goal is a clear indicator of a successful outcome. Choices A, B, and C are incorrect because simply drinking adequate fluids, voiding without difficulty, or feeling less thirsty do not directly demonstrate meeting the specific objective of fluid intake set in the care plan.

2. The healthcare provider is assessing a client who is receiving total parenteral nutrition (TPN). Which finding requires immediate intervention?

Correct answer: C

Rationale: Decreased urine output in a client receiving total parenteral nutrition (TPN) requires immediate intervention because it can indicate potential complications such as fluid overload or kidney dysfunction. Monitoring urine output is crucial in assessing renal function and fluid balance in patients on TPN. A blood glucose level of 150 mg/dL is within a normal range and may not require immediate intervention. Weight gain of 2 pounds in 24 hours could be a concern but may not be as urgent as addressing decreased urine output. A temperature of 100.3°F (37.9°C) is slightly elevated but may not be directly related to TPN administration unless there are other symptoms of infection present.

3. The nurse is developing a series of childbirth preparation classes for primigravida women and their significant others. What is the priority expected outcome for these classes?

Correct answer: A

Rationale: The priority expected outcome for childbirth preparation classes is for participants to be able to identify coping strategies to use during labor. This is crucial as coping strategies can help women manage pain, stress, and anxiety during childbirth. Choice B is important but does not focus on coping strategies needed during labor. Choice C is relevant but focuses solely on pain relief measures which are a part of coping strategies. Choice D is also relevant but does not encompass all aspects of coping with labor effectively.

4. The nurse is documenting the medical history of a young adult who was recently diagnosed with type 1 diabetes mellitus. The client smokes 2 packs of cigarettes a day, and his father died of a heart attack at the age of 45. Which annual screening is most important for the nurse to include?

Correct answer: D

Rationale: The most important annual screening for the nurse to include is hyperlipidemia. Given the client's smoking history, family history of premature heart disease, and the increased risk of cardiovascular complications associated with diabetes, screening for hyperlipidemia is crucial. This screening is essential in assessing the client's risk of developing cardiovascular disease, which is a significant concern in this case. Peripheral neuropathy (choice A) is a common long-term complication of diabetes but may not be the most immediate concern in this scenario. Renal insufficiency (choice B) is also a complication of diabetes, but given the client's high cardiovascular risk, hyperlipidemia screening takes priority. Retinopathy (choice C) is an important complication of diabetes affecting the eyes, but in this case, focusing on cardiovascular risk assessment through hyperlipidemia screening is more critical.

5. A nurse starts classes for clients with type 2 diabetes. Which information would the nurse use as an outcome evaluation for the class?

Correct answer: B

Rationale: A reduction in fasting blood glucose levels indicates the effectiveness of the diabetes management education provided. Monitoring blood glucose levels is a crucial aspect of diabetes management, and a decrease in average readings signifies improvement in managing blood sugar levels. Choices A, C, and D are not direct outcome evaluations related to the effectiveness of the education provided in managing diabetes. Parking convenience, attendance, and teaching strategies are not direct indicators of the impact on the clients' health outcomes.

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