Question

A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing plan of care?

Answer 1

Correct Answers:

Assess the pulses proximal to the fracture site.

Rationale :

🩺Assessing pulses proximal to the fracture site is essential for evaluating arterial blood flow to the affected limb, especially in clients with skeletal traction.

🚨Prompt detection of diminished or absent pulses can indicate complications like compartment syndrome or vascular compromise.

📉Circulatory assessment takes priority over pin site monitoring or pain control because vascular injury can lead to tissue necrosis if not recognized early.

🔗Removing traction is never appropriate unless prescribed, as it would disrupt the fracture alignment and healing process.

📌Core Message

Assessing proximal pulses ensures early detection of vascular impairment and is a critical part of care for clients in skeletal traction.

Answer 2

Correct Answers:

A grandson and his new dog recently visited.

Rationale :

🐶Exposure to a new dog introduces environmental allergens such as dander, which are known triggers for eczema exacerbation.

🪴This is particularly important during flare-ups, where even minor allergens can worsen skin inflammation.

🧴Use of corticosteroid cream is part of treatment and unlikely to worsen symptoms unless there's an adverse reaction.

💉An influenza immunization and visiting someone else with eczema are not typical triggers of eczema flare-ups.

📌Core Message

Environmental allergens, such as pet dander, are common triggers for eczema exacerbations and must be investigated during symptom flares.

Answer 3

Correct Answers:

Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.

Rationale :

💓The client’s tachycardia and tachypnea post-thoracotomy are early signs of hypoxia.

🌬️Administering high-flow oxygen helps stabilize oxygen saturation and addresses potential respiratory compromise.

💊Although pain management is important, it is secondary to correcting oxygen deficits in this case.

📉IV fluids and coughing techniques are not immediate priorities when hypoxemia is suspected.

📌Core Message

Supplemental oxygen is the priority intervention when vital signs indicate hypoxia, especially following thoracic surgery.

Answer 4

Correct Answers:

Uneven hair distribution.

Rationale :

🦵Uneven or sparse hair on the legs is a classic sign of compromised arterial perfusion.

💉Poor circulation deprives hair follicles of nutrients, leading to reduced hair growth.

🌡️Bronze pigmentation and edema are typically associated with venous insufficiency, not arterial problems.

❤️Bounding pulses indicate increased volume or pressure, while arterial compromise usually results in diminished pulses.

📌Core Message

Uneven hair distribution indicates arterial insufficiency due to poor peripheral perfusion.

Answer 5

Correct Answers:

Notify the healthcare provider of the client's medication history.

Rationale :

💉Heparin is an anticoagulant, and its use increases the risk of intraoperative and postoperative bleeding.

📞Informing the healthcare provider allows for adjustments in surgical planning and possible delays.

📋Permit signing and education are important, but they do not address the bleeding risk.

🔍Checking injection sites for bruising is routine but not as urgent as managing medication implications.

📌Core Message

Anticoagulant use must be reported immediately before surgery due to increased bleeding risk.

Answer 6

Correct Answers:

Monitor urine and stool for occult blood regularly.

Rationale :

🩸A platelet count of 25,000/mm³ indicates severe thrombocytopenia, placing the client at risk for spontaneous bleeding.

🔎Monitoring for occult blood helps detect internal bleeding that may not be obvious.

💉Using large-gauge catheters could worsen bleeding risks and is not appropriate here.

🍽️Dietary changes and wrapping bruises are not priority actions when active bleeding is the primary concern.

📌Core Message

In severe thrombocytopenia, monitoring for internal bleeding via stool and urine checks is essential.

Answer 7

Correct Answers:

100

Rationale :

📏The formula for IV infusion rate is Total Volume (mL) ÷ Time (hr).

🧪In this case, 2 liters = 2000 mL, and 20 hours = time.

📉2000 ÷ 20 = 100 mL/hr, which is the correct setting for the infusion pump.

💡Accurate calculations help prevent fluid overload or under-infusion.

📌Core Message

Use the formula Volume ÷ Time to calculate accurate infusion pump rates in mL/hr.

Answer 8

Correct Answers:

Hypovolemia and electrocardiographic (ECG) changes.

Rationale :

💧During the diuretic phase of AKI, the kidneys begin excreting large volumes of dilute urine, leading to fluid loss.

⚡This sudden diuresis can cause electrolyte imbalances, especially hypokalemia, which may show on an ECG.

🩸Creatinine and BUN are still important, but in this phase, monitoring for dehydration and cardiac risks takes precedence.

📉TPN and uremic symptoms are secondary concerns during the diuretic phase.

📌Core Message

In the diuretic phase of AKI, focus on fluid status and electrolyte-related ECG changes.

Answer 9

Correct Answers:

Eating patterns of dietary intake.

Rationale :

🍽️Dietary intake is a key contributor to pain episodes in chronic pancreatitis, as fatty foods can trigger flare-ups.

📋Assessing what, when, and how much the client eats helps the nurse develop effective pain management strategies.

⚠️Bowel sounds and activity levels provide helpful information but don’t directly inform pain triggers.

💩Stool characteristics reflect fat malabsorption, not necessarily pain levels.

📌Core Message

Pain in chronic pancreatitis is often triggered by diet, making eating patterns vital for assessment.

Answer 10

Correct Answers:

Platelet count.

Rationale :

🧬Petechiae and ecchymosis are signs of bleeding under the skin, which often result from thrombocytopenia.

🔬A low platelet count directly correlates with the body's reduced ability to prevent capillary bleeding.

🩸Hemoglobin and RBC levels reflect oxygen-carrying capacity, not clotting function.

🛡️White blood cell count relates to infection resistance, not bleeding.

📌Core Message

Petechiae and ecchymosis signal low platelet counts, making platelet evaluation the top priority.

HESI RN D446 Adult II

No.

1 :
A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing plan of care?

2 :
During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

4 :
The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of compromised peripheral arterial circulation of the lower extremity?

6 :
A client with leukemia is receiving chemotherapy. The nurse observes the client is weak, pale, and febrile. After reviewing the client's most recent laboratory results which reveals a platelet count of 25,000/mm3 (25 x 10^9/L), which intervention should the nurse include in the plan of care?

7 :
A client receives a prescription for 2 liters of lactated Ringer's IV to be infused over 20 hours. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

8 :
A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor?

9 :
The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

10 :
The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?

HESI RN D446 Adult II

No.

1 : A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing plan of care?

2 : During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

4 : The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of compromised peripheral arterial circulation of the lower extremity?

6 : A client with leukemia is receiving chemotherapy. The nurse observes the client is weak, pale, and febrile. After reviewing the client's most recent laboratory results which reveals a platelet count of 25,000/mm3 (25 x 10^9/L), which intervention should the nurse include in the plan of care?

7 : A client receives a prescription for 2 liters of lactated Ringer's IV to be infused over 20 hours. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

8 : A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor?

9 : The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

10 : The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?

1 :
A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing plan of care?

2 :
During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

4 :
The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of compromised peripheral arterial circulation of the lower extremity?

6 :
A client with leukemia is receiving chemotherapy. The nurse observes the client is weak, pale, and febrile. After reviewing the client's most recent laboratory results which reveals a platelet count of 25,000/mm3 (25 x 10^9/L), which intervention should the nurse include in the plan of care?

7 :
A client receives a prescription for 2 liters of lactated Ringer's IV to be infused over 20 hours. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

8 :
A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor?

9 :
The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

10 :
The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?