When assessing a client with left-sided heart failure, which intervention should the nurse implement first?- Skildor

Question 1 of 5

When assessing a client with left-sided heart failure, which intervention should the nurse implement first?

A. Administer oxygen therapy as prescribed. B. Monitor the client's urine output. C. Administer a loop diuretic as prescribed. D. Administer morphine as prescribed.

Correct Answer: A

Rationale: Administering oxygen therapy is the initial intervention for a client with left-sided heart failure. This action is crucial in improving oxygen levels and reducing pulmonary congestion. Monitoring urine output is important for assessing renal function in heart failure, but it is not the priority over ensuring adequate oxygenation. Administering loop diuretics helps manage fluid overload but should come after addressing oxygen needs. Morphine may be indicated for pain or anxiety in some cases, but it is not the primary intervention for left-sided heart failure.

Question 2 of 5

The nurse is caring for a client who is postoperative following a thyroidectomy. Which finding requires immediate intervention?

A. Hoarse voice B. Slight difficulty swallowing C. Positive Chvostek's sign D. Pain at the incision site

Correct Answer: C

Rationale: A positive Chvostek's sign indicates hypocalcemia, a common complication following thyroidectomy due to inadvertent parathyroid gland injury. Immediate intervention is needed to prevent severe hypocalcemia symptoms like tetany, seizures, and laryngospasm. Hoarse voice and slight difficulty swallowing are expected post-thyroidectomy and do not require immediate intervention. Pain at the incision site is common postoperatively and can be managed with appropriate pain relief measures.

Question 3 of 5

A newly graduated female staff nurse approaches the nurse manager and requests reassignment to another client because a male client is asking her for a date and making suggestive comments. Which response is best for the nurse manager to provide?

A. I have to call the supervisor to get someone else to transfer to this unit to care for him. B. I know you are a good nurse and can handle this client in a professional manner. C. I'll talk to the client about his sexual harassment and insist that he stop immediately. D. I'll change your assignment, but let's talk about how a nurse should respond to this kind of client.

Correct Answer: D

Rationale: The best response for the nurse manager is option D. Changing the assignment while providing guidance on professional boundaries and how to handle such situations is essential. Option A is not appropriate as it does not address the issue of the client's behavior. Option B, although supportive, does not offer a solution to the problem at hand. Option C is not the best approach as directly confronting the client about sexual harassment may escalate the situation further.

Question 4 of 5

The nurse is administering an IV medication to a client with a history of anaphylaxis. Which intervention is most important for the nurse to implement?

A. Stay with the client throughout the infusion. B. Keep emergency resuscitation equipment at the bedside. C. Obtain the client's allergy history. D. Ask the client about past allergic reactions to medications.

Correct Answer: B

Rationale: Keeping emergency resuscitation equipment at the bedside is crucial in case the client experiences anaphylaxis during the infusion. While staying with the client throughout the infusion (Choice A) is important, having immediate access to emergency equipment takes priority in this situation. Obtaining the client's allergy history (Choice C) and asking about past allergic reactions to medications (Choice D) are relevant but do not address the immediate need for emergency intervention in case of anaphylaxis.

Question 5 of 5

When organizing home visits for the day, which older client should the home health nurse plan to visit first?

A. A woman who takes naproxen (Naprosyn) and reports a recent onset of dark, tarry stools. B. A man who receives weekly injections of epoetin (Procrit) for a low serum iron level. C. A man with emphysema who smokes and is complaining of white patches in his mouth. D. A frail woman with heart failure who reported a 2-pound weight gain in the last week.

Correct Answer: A

Rationale: The correct answer is A. Dark, tarry stools may indicate gastrointestinal bleeding, a potentially life-threatening condition that requires immediate attention. Visiting this client first is crucial for prompt assessment and intervention. Choices B, C, and D do not present immediate life-threatening conditions that require urgent attention compared to the potential emergency indicated by dark, tarry stools.

HESI 799 RN Exit Exam Quizlet

Skildor

HESI RN

HESI RN

HESI 799 RN Exit Exam Quizlet Questions

Question 1 of 5

Question 2 of 5

Question 3 of 5

Question 4 of 5

Question 5 of 5

Similar Questions

Join Our Community Today!