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
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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 in the intensive care unit is started on continuous venovenous hemofiltration (CVVH). Which finding should prompt immediate action by the nurse?

Correct answer: A

Rationale: The correct answer is A: Blood pressure of 76/58 mm Hg. In a client undergoing continuous venovenous hemofiltration (CVVH), hypotension can be a significant concern if replacement fluid does not adequately maintain blood pressure. The nurse should take immediate action to address hypotension to prevent further complications. The sodium level of 138 mEq/L is within normal range, and a potassium level of 5.5 mEq/L, while slightly elevated, may be expected in a patient with acute kidney injury. A pulse rate of 90 beats/min falls within the normal range and does not typically require immediate intervention in this context.

3. Which instruction should be included in the discharge teaching plan for a client who underwent cataract extraction today?

Correct answer: D

Rationale: The correct instruction to include in the discharge teaching plan for a client who underwent cataract extraction is to advise them that light housekeeping is safe to do, but they should avoid heavy lifting. Heavy lifting can strain the surgical site and potentially lead to complications. Choice A is incorrect as a metal eye shield is usually recommended during sleep, not during the day. Choice B is incorrect because eye ointment should typically be administered after applying eye drops to prevent dilution of the medication. Choice C is incorrect as sexual activities should usually be avoided for a specific period post-surgery as advised by the healthcare provider.

4. The client with chronic renal failure is being taught about the importance of fluid restrictions. Which of the following statements by the client indicates that the teaching has been effective?

Correct answer: B

Rationale: The correct answer is B: 'I will need to limit my fluid intake to prevent fluid overload.' In chronic renal failure, fluid restrictions are crucial to prevent fluid overload and further damage to the kidneys. Option A is incorrect as unrestricted fluid intake can worsen the condition. Option C is also incorrect as total fluid intake needs to be restricted, not just other fluids. Option D is not ideal because thirst may not accurately reflect the body's fluid needs in chronic renal failure.

5. The nurse is providing discharge teaching to a client with coronary artery disease (CAD). Which of the following statements by the client indicates a need for further teaching?

Correct answer: A

Rationale: The statement indicates a misunderstanding because medication for CAD should be taken as prescribed, not only when chest pain occurs.

Similar Questions

A patient’s serum osmolality is 305 mOsm/kg. Which term describes this patient’s body fluid osmolality?
The healthcare provider prescribes diagnostic tests for a client with pneumonia identified on a chest X-ray. Which diagnostic test should the nurse review for implementation to guide the most therapeutic treatment of pneumonia?
Blood is drawn from a client with suspected uric acid calculi for a serum uric acid determination. Which value does the nurse recognize as a normal uric acid level?
Which electrolyte imbalance is most likely to be seen in a patient with chronic kidney disease?
Which of the following symptoms would a healthcare provider expect to find in a patient with hyperkalemia?

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