the nurse is preparing to administer an antibiotic to a patient who has been receiving the antibiotic for 2 days after a culture was obtained the nurs
Logo

Nursing Elites

HESI RN

RN Medical/Surgical NGN HESI 2023

1. The nurse is preparing to administer an antibiotic to a patient who has been receiving the antibiotic for 2 days after a culture was obtained. The nurse notes increased erythema and swelling, and the patient has a persistent high fever of 39°C. What is the nurse’s next action?

Correct answer: D

Rationale: In this scenario, the nurse is observing signs of a possible lack of response to the current antibiotic therapy, such as increased erythema, swelling, and persistent high fever. The next appropriate action for the nurse is to review the sensitivity results from the patient’s culture. This step is crucial to determine if the current antibiotic is effective against the causative organism. If the sensitivity results indicate resistance to the current antibiotic, the antibiotic should be discontinued, and the provider should be notified for a change in therapy. Contacting the provider to request another culture is not the immediate priority, as the existing culture results need to be reviewed first. Adding a second antibiotic should only be considered after confirming the sensitivity results, as unnecessary antibiotic use can lead to antimicrobial resistance.

2. A client was admitted for a myocardial infarction and cardiogenic shock 2 days ago. Which laboratory test result should a nurse expect to find?

Correct answer: A

Rationale: In cardiogenic shock, decreased renal perfusion leads to an elevated BUN. Choice A is correct. Creatinine remains normal in cardiogenic shock as it signifies kidney damage, which has not occurred in this case. A low BUN indicates overhydration, malnutrition, or liver damage, which are not typically seen in cardiogenic shock. A low BUN/creatinine ratio is associated with fluid volume excess or acute renal tubular acidosis, not specifically indicative of cardiogenic shock.

3. What is an expected outcome when a client is receiving an IV administration of furosemide?

Correct answer: B

Rationale: The correct answer is B: Increased urine output. Furosemide is a loop diuretic that works by inhibiting the reabsorption of sodium and chloride in the ascending loop of Henle in the kidneys, leading to increased urine production. This diuretic effect helps to reduce fluid volume in the body, making it an expected outcome when a client is receiving furosemide. Choice A, increased blood pressure, is incorrect because furosemide typically causes a decrease in blood pressure due to its diuretic effect. Choice C, decreased pain, and choice D, decreased premature ventricular contractions, are unrelated to the pharmacological action of furosemide.

4. After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hours. What priority nursing action should be implemented?

Correct answer: A

Rationale: In this situation, the nurse's priority action should be to report the findings to the surgeon. An adult should typically produce about 60 ml of urine per hour, so a dark, concentrated, and low urine output of 54 ml over 2 hours raises concerns. This change in urine output may indicate issues such as dehydration, renal problems, or inadequate fluid intake. Reporting this finding to the surgeon is crucial to ensure appropriate evaluation and intervention. Irrigating the catheter, applying manual pressure to the bladder, or increasing the IV flow rate are not appropriate actions based on the information provided and could potentially worsen the situation.

5. A nurse is conducting an assessment of a client who underwent thoracentesis of the right side of the chest 3 hours ago. Which findings does the nurse report to the physician? Select all that apply.

Correct answer: A

Rationale: After thoracentesis, the nurse should assess the client for signs of pneumothorax, which include increased respiratory rate, dyspnea, retractions, unequal chest expansion, diminished breath sounds, and cyanosis. Unequal chest expansion is a key sign of pneumothorax due to the accumulation of air in the pleural space, causing the affected lung to collapse partially. Pulse rate and respiratory rate within normal ranges, like in choices B and C, are not the priority findings to report in this situation. Diminished breath sounds in the right lung could be expected after thoracentesis and may not necessarily indicate a complication like pneumothorax, making choice D less urgent to report.

Similar Questions

A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about:
The client with chronic renal failure is being educated on dietary restrictions. Which of the following foods should the client avoid?
A client has just regained bowel sounds after undergoing surgery. The physician has prescribed a clear liquid diet for the client. Which of the following items should the nurse ensure is available in the client’s room before allowing the client to drink?
A patient is taking a thiazide diuretic and reports anorexia and fatigue. The nurse suspects which electrolyte imbalance in this patient?
Which of the following is a common sign of meningitis?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses