which is the best position for a client experiencing a nosebleed
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Nursing Elites

HESI LPN

Medical Surgical Assignment Exam HESI

1. What is the best position for a client experiencing a nosebleed?

Correct answer: A

Rationale: The best position for a client experiencing a nosebleed is sitting up and leaning forward. This position helps prevent blood from flowing down the throat and reduces the risk of aspiration. Choice B is incorrect as lying flat can lead to blood flowing down the throat. Choice C is also incorrect because leaning back may cause blood to flow backward into the throat. Choice D is incorrect as lying on the side with the head elevated is not the optimal position to manage a nosebleed effectively.

2. An older client is receiving an IV of 5% dextrose in 0.45% normal saline at 75 mL/hour. Which assessment finding indicates to the nurse that the client is developing a complication from this therapy?

Correct answer: D

Rationale: The correct answer is D. Tachycardia and dyspnea are signs of fluid overload, which is a potential complication of IV fluid therapy. Choices A, B, and C are not directly related to fluid overload and are not typical signs of complications associated with the IV fluid therapy being administered.

3. What is the most common clinical manifestation of coarctation of the aorta?

Correct answer: B

Rationale: The correct answer is B: Upper extremity hypertension. Coarctation of the aorta leads to increased blood pressure in the upper extremities. The pressure in the arms is typically 20 mm Hg higher than in the legs. Choice A, clubbing of the digits, is not a common clinical manifestation of coarctation of the aorta. Choice C, pedal edema, and portal congestion are more suggestive of conditions like heart failure rather than coarctation of the aorta. Choice D, loud systolic ejection murmur, can be heard in conditions like aortic stenosis, but it is not the most common clinical manifestation of coarctation of the aorta.

4. A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained and leaves the present IV in place. What is the greatest clinical risk related to this situation?

Correct answer: A

Rationale: The correct answer is A: Impaired skin integrity. In this situation, the greatest clinical risk is related to impaired skin integrity due to the potential extravasation of the vesicant. Vesicants are substances that can cause severe tissue damage if they leak into the surrounding tissues. Choices B, C, and D are not the most significant risks in this scenario. Fluid volume excess, acute pain, and peripheral neurovascular dysfunction are not directly associated with leaving the IV in place with a known vesicant for an extended period.

5. A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply)

Correct answer: C

Rationale: It is crucial for the nurse to evaluate the application of the splint to the left leg in a client with diminished distal pulses. This assessment helps ensure that the splint is not causing any compromise to circulation. Verifying pulses and monitoring for leg conditions are important interventions but do not directly address the issue with the splint application in this scenario, making them less relevant.

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