ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (202 3/2024) 271. A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action should the nurse take? (correct Answer - Administer the medication as prescribed with a glass of water 272. Which client should the nurse assess frequently because of the risk for overflow incontinence? A client Who is confused and frequently forgets to go to the bathroom 273. While monitoring a client during a seizure, which interventions should the nurse implement? (Select all that apply) (correct Answer - Move obstacle away from client Monitor physical movements Observe for a patent airway Record the duration of the seizure 274. A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2023/2024) Which intervention is most important for the nurses to include in the client's plan of care? (correct Answer - Observe for changes in level of consciousness. 275. An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) resu lts after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client's ABG finding, which action is required? correct Answer - Increase ventilator rate. 276. The mother of the 12 - month -old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experiences a loss of appetite. What instruction should the nurse provide? (correct Answer - CPT should be performed more frequently, but at least an hour before meals. 277. The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendationfor hypertension? (correct Answer - Baked pork chop, applesauce, corn on the cob, 2% milk, and key - lime pie 278. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include in this client's plan of care? (correct Answer - Fingerstick glucose assessment q6h with meals Review with the client proper foot care and prevention of injury Coordinate carbohydrate controlled meals at consistent times and intervals Teach subcutaneous injection technique, site rotation and insulin management 279. Which problem reported by a client taking lovastatin requires the most immediate fallow up by the nurse? (correct Answer - Muscle pain 280. While assessing a client's chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client's vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/mi nutes, oxygen saturation 88%. Which interventions should the nurse implement? (correct Answer - Provide supplemental oxygen Auscultate bilateral lung fields Reinforce occlusive CT dressing 281. 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 - Ensure that the knot can be quickly released. 282. Oral antibiotics are prescribed for an 18 -month -old toddler with severe otitis media. An antipyrine and benzocaine -otic also prescribed for pain and inflammation. What instruction should the n urse emphasize concerning the installation of the antipyrine/benzocaine otic solution? (correct Answer - Have the child lie with the ear up for one to two minute after installation. 283. An older adult male is admitted with complications related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide? (correct Answer - Restrict daily fluid intake. 284. The nurse inserts an indwelling urinary catheter as seen in the video what action should the nurse take next? (correct Answer - Leave the catheter in place and obtain a sterile catheter.
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