the nurse is caring for a client with dehydration which assessment finding indicates that the client is responding to treatment
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Nursing Elites

HESI LPN

HESI Fundamentals 2023 Quizlet

1. The healthcare provider is caring for a client with dehydration. Which assessment finding indicates that the client is responding to treatment?

Correct answer: B

Rationale: Increased urine output is the correct assessment finding that indicates the client is responding to treatment for dehydration. When a client is dehydrated, their urine output tends to decrease as the body tries to conserve fluids. Therefore, an increase in urine output suggests that the client's hydration status is improving. Dry mucous membranes (Choice A) are a sign of dehydration and would not indicate a positive response to treatment. Decreased heart rate (Choice C) and elevated blood pressure (Choice D) are not specific indicators of hydration status in a client with dehydration.

2. A client who is 3 days post-op following a cholecystectomy has yellow and thick drainage on the dressing. The nurse suspects a wound infection. The nurse identifies this type of drainage as:

Correct answer: A

Rationale: The correct answer is A: Purulent. Purulent drainage is thick, yellow, and indicates the presence of infection. This type of drainage is typically seen in infected wounds. Choice B, Serous drainage, is thin, clear, and watery, which is normal in the initial stages of wound healing. Sanguineous drainage, choice C, is bright red and indicates fresh bleeding. Serosanguineous drainage, choice D, is pale pink to red and is a mixture of blood and serous fluid commonly seen in the early stages of wound healing.

3. To ensure the safety of a client receiving a continuous intravenous normal saline infusion, how often should the LPN change the administration set?

Correct answer: D

Rationale: The correct answer is to change the administration set every 72 to 96 hours. This practice helps reduce the risk of infection by preventing the build-up of bacteria in the tubing. Changing the set too frequently (choices A, B, and C) may increase the chances of contamination and infection without providing additional benefits. Therefore, the LPN should follow the guideline of changing the administration set every 72 to 96 hours to maintain the client's safety during the continuous intravenous normal saline infusion.

4. The nurse is caring for a client diagnosed with hypothyroidism. Which finding should the nurse expect to observe?

Correct answer: A

Rationale: The correct answer is weight gain. In hypothyroidism, there is a decrease in metabolic rate, which can lead to weight gain. Heat intolerance (choice B) is more commonly associated with hyperthyroidism. Increased appetite (choice C) and frequent diarrhea (choice D) are not typical findings in hypothyroidism. Therefore, choices B, C, and D are incorrect.

5. A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first?

Correct answer: A

Rationale: The nurse should prioritize seeing the client who has new onset dyspnea 24 hours after a total hip arthroplasty first. This sudden dyspnea could indicate a serious complication like a pulmonary embolism, which requires immediate assessment and intervention. Acute abdominal pain, a UTI with a low-grade fever, and pneumonia with an oxygen saturation of 96% are important concerns but are not as immediately life-threatening as potential pulmonary embolism indicated by sudden dyspnea postoperatively.

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