the nurse is teaching the parent of a child newly diagnosed with a latex allergy which information by the parents indicates a need for further teachin
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Nursing Elites

HESI RN

Adult Health 2 HESI Quizlet

1. The nurse is teaching the parent of a child newly diagnosed with a latex allergy. Which information by the parents indicates a need for further teaching?

Correct answer: C

Rationale: The correct answer is C. Bananas and kiwis are foods that can cross-react with latex allergy, indicating that the parents need further teaching on managing latex allergies. Choices A, B, and D are correct as rubber-free toys, using foil balloons, and having an epinephrine auto-injector are appropriate measures to prevent and manage allergic reactions in a child with a latex allergy.

2. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?

Correct answer: C

Rationale: The priority is to ensure that the knot can be quickly released to allow for quick intervention if necessary. Tying the knot with a double turn or square knot (Choice A) may make it more difficult to release quickly in an emergency. Ensuring that the restraints are snug against the client's wrists (Choice B) may compromise circulation and cause discomfort. Moving the ties to secure the restraints to the side rails (Choice D) is not the appropriate action as it can limit the client's movement and access to care.

3. After receiving change-of-shift report, which patient should the nurse assess first?

Correct answer: C

Rationale: The correct answer is patient C with a serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes. The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures, which are life-threatening. Assessing and addressing this patient's condition promptly is crucial to prevent complications. Patients A, B, and D have mild electrolyte disturbances or symptoms that require attention, but they are not at immediate risk for life-threatening complications like seizures, unlike patient C.

4. A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of "just blowing up" and has peripheral edema and shortness of breath. Which assessment should the nurse complete first?

Correct answer: C

Rationale: Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema.

5. A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?

Correct answer: A

Rationale: The correct answer is A - 'The patient is experiencing laryngeal stridor.' Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patient’s calcium level to prevent a life-threatening situation. Choices B, C, and D are also symptoms of hypocalcemia, but laryngeal stridor takes precedence due to its potential to quickly progress to a critical condition.

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