First-level problems are immediate
priorities (airway, breathing, and
366 EXIT HESI circulation). In this scenario, airway
and breathing are the first priority,
EXAM followed by pain management,
QUESTIONS AND Maslow's hierarchy of basic needs for
rest and sleep, and then definitive
ANSWERS 2024 drug therapies.
A newly admitted client complains of
pain rating a 7 on a scale of 0 to 10. Which biological practices are
The client has not been sleeping well federally regulated for healthcare
lately and is experiencing labored workers? (Select all that apply.)
breathing. List the client's problems in Select all that apply
order of priority for the nurse. (Rank
in the priority order from highest to
lowest.) 1.Standard precautions.
1. 2. N-95 tuberculosis standard.
Airway and breathing. 3. Blood-borne pathogen standard.
2. 4. Biological product exposure limit
(BPEL).
Pain management.
5. Resource Conservation and
3.
Recovery Act (RCRA).
Definitive therapy.
6. As Low as Reasonably Allowable
4. standard (ALARA). - 3. Blood-borne
Sleep and rest. - Correct Answer: pathogen standard.
1.Airway and breathing. 2.Pain 5. Resource Conservation and
management. 3.Sleep and rest. Recovery Act (RCRA)
4.Definitive therapy.
Rationale Basic standards for healthcare
workers, as delineated by
Occupational Safety and Health
Administration (OSHA), include
,standard precautions, droplet Stating the observation that others
precautions using N-95 respiratory have recovered can give a client hope.
particulate masks when caring for a Telling a person to stop negtive
client who is positive for tuberculosis, thinking is ineffective because the
and required annual updates for client must be taught cognitive
healthcare workers about blood-borne strategies to stop negative thinking.
pathogen transmission, methods of Stating the person is "no bother" is
minimizing exposure, and employee arguing with the client's beliefs and
rights. Other options [BPEL and attempting to tell him how to feel,
ALARA ] are not federally regulated. both of which are not therapeutic
responses. Bring up pessimistic
feelings interprets the client's feelings
A client with severe depression tells and does not provide the same degree
the nurse, "I do not know why you of hope.
bother with me or give me pills. I am
never going to get well." What is the
most therapeutic response? The nurse is caring for a client with a
nursing problem of, "Infection, risk
1. "You need to stop thinking negative
for, related to inadequate primary
thoughts. They get in the way of your
defenses as evidenced by surgical
recovery."
incision and IV access." What nursing
2. "You are no bother to me or to the intervention should the nurse
staff. We want you to get well and not implement?
feel sad anymore."
1. Limit visitors to immediate family
3. "I have known many clients with to decrease exposure to infection.
depression who have felt better after
2. Maintain "clean" technique in the
several weeks of treatment."
change of wound dressing and IV site.
4. "You are feeling very pessimistic,
3. Assess and document skin
but that is part of your illness. It
condition around the incision and IV
should go away as you recover." - 3.
site at each shift.
"I have known many clients with
depression who have felt better after 4. Require the use of a face mask by
several weeks of treatment." staff when providing care requiring
close contact. - 3. Assess and
document skin condition around the
incision and IV site at each shift.
, the anastomosed parts of the colon, a
temporary loop ostomy is created, not
Early identification of infection leads
a permanent one. Although appliances
to prompt treatment and decreased
that are easy to use are advantageous,
nosocomial transmission to others, so
the ostomy is reversed after healing
the condition of any invasive lines or
takes place. Stool drains into the
breaks in the skin should be assessed
reservoir, so daily irrigation is not
and documented during each shift.
usually indicated.
A client with ulcerative colitis is
The nurse inflates the cuff on a
scheduled for surgical creation of an
tracheostomy tube to minimal
ileoanal reservoir (J pouch). As part of
occlusion pressure for a client who is
preoperative teaching, what
breathing spontaneously. Which
information should the nurse provide?
action should the nurse follow?
1. The transverse loop ostomy is
1. Check the pilot balloon to ensure
permanent.
that it is firm.
2. Easily removable appliances allow
2. Verify the healthcare provider's
independence in self-care.
prescription for the required cuff
3. Daily irrigation is started after the J pressure.
pouch heals.
3. Use a manometer to maintain cuff
4. Stool is eventually expelled pressure between 25 and 30 mmHg.
through the rectum. - 4. Stool is
4. Inject air until no air is auscultated
eventually expelled through the
over the larynx during a deep breath. -
rectum.
4. Inject air until no air is auscultated
over the larynx during a deep breath.
An ileal pouch-anal anastomosis (also To achieve minimal pressure (minimal
known as the J pouch) is a surgically occlusion volume technique) against
created ileoanal reservoir in the anal the tracheal wall, inject air into the
canal that preserves the rectal tracheostomy tube cuff while
sphincter muscle, so that passage of auscultating with a stethoscope placed
stool through the rectum is the over the larynx (over the cuff) during
eventual result. To promote healing of inhalation. At the point when sounds
, of air movement cease, inflation is neither causes disease nor is
stopped, indicating that the cuff is communicable.
sealed against the tracheal wall.
Which contextual factors are
A 60-year-old homeless man who considered external environmental
complains of a cough, late-afternoon influences in the framework for
fever, and night sweats has a 10 mm occupational health programs and
induration after receiving a purified services? (Select all that apply.)
protein derivative (PPD) skin test.
Select all that apply
Which action should the nurse
implement? 1. Economics.
1. Refer for further diagnostic 2. Workforce.
evaluation. 3. Technology.
2. Determine exposure of others to the 4. Interventions.
tuberculosis.
5. Socio-economic status.
3. Begin anti-tubercular drug therapy.
6. Legislation/regulation. - 1.
4. Quarantine or isolate to control Economics.
communicability. - 1. Refer for further
diagnostic evaluation. 3. Technology.
6. Legislation/regulation.
The PPD skin test results is indicative
of exposure or latent Mycobacterium Economics affects the health of the
tuberculosis infection (LTBI), which company and its workforce
this client is in a high-risk category productivity, in termsof profitability,
for exposure in a homeless growth, and expansion. Technology
environment. Although productive adds to an industry's capacity to
prolonged cough, fever, and night develop and implement new or
sweats are common early symptoms, improved work processes.
persons suspected of LTBI should not Legislation/regulation in the
begin treatment until active TB workplace, such as the blood-borne
disease has been excluded. Further pathogen standard, affects the
diagnostic evaluation should be workforce in terms of requirements,
implemented. A dormant form that administration, and control strategies.
