the nurse is taking the vital signs of a client after hemodialysis blood pressure is 11058 mm hg pulse 66 beatsmin and temperature is 998 f 376 c what
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Nursing Elites

HESI RN

RN Medical/Surgical NGN HESI 2023

1. The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/58 mm Hg, pulse 66 beats/min, and temperature is 99.8°F (37.6°C). What is the most appropriate action by the nurse?

Correct answer: C

Rationale: After hemodialysis, it is crucial to monitor the client's temperature because the dialysate is warmed to increase diffusion and prevent hypothermia. The client's temperature might reflect the temperature of the dialysate. There is no need to administer fluids to increase blood pressure as the vital signs are within normal limits. Checking the white blood cell count or connecting the client to an ECG monitor is not necessary based on the information provided.

2. The client is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?

Correct answer: A

Rationale: Protecting the skin from sunlight exposure is crucial to prevent radiation burns and additional skin damage at the treatment site. Sun exposure can exacerbate skin reactions caused by radiation therapy. Applying moisturizing lotions daily may introduce foreign substances or irritants to the treated area, leading to potential complications. Washing the skin inside the radiation portal site is important for maintaining cleanliness and preventing infections. Removing the ink marks after each treatment is unnecessary and may cause unnecessary skin irritation and trauma.

3. Blood for arterial blood gas determinations is drawn from a client with pneumonia, and testing reveals a pH of 7.45, PCO2 of 30 mm Hg, and HCO3 of 19 mEq/L. The nurse interprets these results as indicative of:

Correct answer: B

Rationale: The correct answer is 'Compensated respiratory alkalosis.' In this case, the client's pH is within the normal range (7.35-7.45), indicating compensation. The low PCO2 (30 mm Hg) suggests respiratory alkalosis, while the low HCO3 (19 mEq/L) is also consistent with a compensatory response. Therefore, the client has a primary respiratory alkalosis that is being compensated for by metabolic acidosis. Choices A, C, and D are incorrect because they do not fit the pattern of the given blood gas values, which indicate respiratory alkalosis with metabolic compensation.

4. Oxygen via nasal cannula has been prescribed for a client with emphysema. The nurse checks the physician’s orders to ensure that the prescribed flow is not greater than:

Correct answer: B

Rationale: The correct answer is B, 3 L/min. Clients with emphysema typically receive oxygen at a flow rate of 1 to 2 L/min, with a maximum of 3 L/min. Higher flow rates can lead to oxygen toxicity in these clients, so it's crucial to adhere to the prescribed limits. Choice A (1 L/min) is too low and may not provide adequate oxygenation for the client. Choices C (4 L/min) and D (6 L/min) exceed the recommended flow rates for clients with emphysema and can increase the risk of oxygen toxicity.

5. A patient asks the nurse about taking calcium supplements to avoid hypocalcemia. The nurse will suggest that the patient follow which instruction?

Correct answer: A

Rationale: The correct answer is to take a calcium and vitamin D combination supplement. Vitamin D enhances the absorption of calcium in the body, making it an essential component for calcium utilization. Choice B is incorrect because calcium and phosphorus have an inverse relationship, where an increased level of one mineral decreases the level of the other, so taking them together may not be beneficial. Choice C is incorrect because antacids often contain magnesium, which can promote calcium loss instead of absorption. Choice D is incorrect because aspirin can alter vitamin D levels and interfere with calcium absorption, so it is not recommended when taking calcium supplements.

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