which intervention is most important to include in the plan of care for a client at high risk for the development of postoperative thrombus formation
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Nursing Elites

HESI RN

HESI Quizlet Fundamentals

1. Which intervention is most important to include in the plan of care for a client at high risk for the development of postoperative thrombus formation?

Correct answer: D

Rationale: Thrombus formation is a risk for clients who are immobile postoperatively. Encouraging frequent ambulation helps to prevent stasis in the lower extremities, reducing the risk of thrombus formation. This intervention promotes circulation and prevents blood clot formation, making it the most important intervention in this situation.

2. A female client with chronic back pain has been taking muscle relaxants and analgesics to manage the discomfort, but is now experiencing an acute episode of pain that is not relieved by this medication regimen. The client tells the nurse that she does not want to have back surgery for a herniated intervertebral disk, and reports that she has found acupuncture effective in resolving past acute episodes. Which response is best for the nurse to provide?

Correct answer: D

Rationale: Acknowledging the effectiveness of acupuncture is important, as the client has reported its success in managing her pain previously.

3. The nurse is preparing to administer 2 units of packed red blood cells (PRBCs) to a client. Which action should the nurse implement to ensure the client’s safety?

Correct answer: D

Rationale: Verifying the blood type and crossmatch with another licensed nurse is crucial to prevent transfusion reactions and ensure the client's safety. This step helps confirm that the correct blood type is being transfused to the client, reducing the risk of adverse reactions and promoting safe care. Obtaining informed consent (Choice A) is important but not directly related to ensuring the safety of the transfusion. Reviewing the client's medical history for transfusion reactions (Choice B) is relevant but not as crucial as verifying the blood type and crossmatching. Assessing baseline vital signs (Choice C) is a routine practice before transfusion but ensuring the correct blood type is a higher priority.

4. During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse?

Correct answer: D

Rationale: The best response for the nurse is to ask the client to talk about specific concerns. This approach provides an opportunity for the client to express her worries openly, allowing the nurse to gather more detailed information for a comprehensive assessment and to address the client's concerns effectively.

5. During the admission assessment of a terminally ill male client, he states that he is an agnostic. What is the best nursing action in response to this statement?

Correct answer: B

Rationale: Documenting the client's statement in the spiritual assessment is the best nursing action in response to his disclosure of being an agnostic. This respects the client's beliefs and preferences, ensuring that care is tailored to his individual needs. It also demonstrates a commitment to providing holistic and patient-centered care. Providing information about the chapel's hours and location (choice A) may not align with the client's beliefs as an agnostic. Inviting the client to a healing service (choice C) assumes the client's interest in such activities, which may not be the case. Offering to contact a spiritual advisor (choice D) may not be necessary if the client did not express a desire for it.

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