A client is admitted for first and second degree burns on the face, neck, anterior chest, and hands. The nurse's priority should be- Skildor

Question 1 of 5

A client is admitted for first and second degree burns on the face, neck, anterior chest, and hands. The nurse's priority should be

A. Cover the areas with dry sterile dressings B. Assess for dyspnea or stridor C. Initiate intravenous therapy D. Administer pain medication

Correct Answer: B

Rationale: The correct answer is to assess for dyspnea or stridor. In burn cases involving the face, neck, or chest, there is a risk of airway compromise due to swelling. Dyspnea (difficulty breathing) or stridor (noisy breathing) can indicate airway obstruction or respiratory distress, which requires immediate intervention. Covering the burns with dry sterile dressings (choice A) can be important but ensuring airway patency takes precedence. Initiating intravenous therapy (choice C) may be necessary but not the priority over assessing the airway. Administering pain medication (choice D) is important for comfort but should come after ensuring the airway is clear and breathing is adequate.

Question 2 of 5

A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these?

A. Apply appropriate signs outside and inside the room B. Apply a mask with a shield if there is a risk of fluid splash C. Wear a gown to change soiled linens from incontinence D. Have gloves on while handling bedpans with feces

Correct Answer: D

Rationale: The correct answer is to have gloves on while handling bedpans with feces. Hepatitis A is transmitted through the fecal-oral route, and using gloves during such direct contact with feces is crucial in preventing the transmission of the infection. Choice A is not directly related to infection control for hepatitis A. Choice B is more relevant to preventing droplet transmission rather than fecal-oral transmission. Choice C is important for preventing contact transmission from soiled linens but is not as directly related to the mode of transmission of hepatitis A as using gloves when handling feces.

Question 3 of 5

The nurse is caring for a client who requires a mechanical ventilator for breathing. The high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?

A. Disconnect the client from the ventilator and use a manual resuscitation bag B. Perform a quick assessment of the client's condition C. Call the respiratory therapist for help D. Press the alarm reset button on the ventilator

Correct Answer: B

Rationale: When the high-pressure alarm on a ventilator goes off, the nurse's initial action should be to perform a quick assessment of the client's condition. This assessment helps in promptly identifying the cause of the alarm, such as mucus plugging, kinking of the tubing, or other issues. By assessing the client first, the nurse can determine the appropriate intervention needed to address the alarm. Choices A and D are incorrect because disconnecting the client from the ventilator or pressing the alarm reset button should not be the initial actions without assessing the client's condition. While calling the respiratory therapist for help could be beneficial, assessing the client's condition should be the nurse's priority to address the immediate concern.

Question 4 of 5

A client who had a vasectomy is in the post-recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?

A. Until the healthcare provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception. B. This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen, and no sperm are in your ejaculate. C. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days. D. The healthcare provider at this clinic recommends rest, ice, an athletic supporter, or over-the-counter pain medication to relieve any discomfort.

Correct Answer: A

Rationale: The most crucial point to reinforce to the patient after a vasectomy is the need for continued contraception until it is confirmed that the ejaculate is sperm-free. Choice A emphasizes this by highlighting the importance of using another form of contraception until the healthcare provider confirms the absence of sperm. This is essential to prevent unintended pregnancies. Choices B, C, and D do not address the key point of ensuring contraception until sperm absence is confirmed and are therefore not as important to reinforce in this scenario.

Question 5 of 5

A nurse is reinforcing nutrition teaching with a client who has osteoporosis. Which of the following food selections should the nurse recommend to increase calcium in the client's diet?

A. 1 medium apple B. 3 oz of lean beef C. 1 tbsp of cream cheese D. 1 cup of kale

Correct Answer: D

Rationale: The correct answer is D: 1 cup of kale. Kale is rich in calcium, making it a suitable choice to increase calcium intake for individuals with osteoporosis. While fruits like apples (choice A) are nutritious, they are not high in calcium. Lean beef (choice B) is a good source of protein but not a significant source of calcium. Cream cheese (choice C) is also not a primary source of calcium compared to kale.

HESI Nutrition Practice Exam

Skildor

HESI RN

HESI RN

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