2018 HESI EXIT V5

41. A client experiences postpartum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breast feed the infants. Which of the following is based on sound rationale? A) "Nursing will help contract the uterus and reduce your risk of bleeding." B) "Breastfeeding twins will take too much energy after the hemorrhage." C) "The blood transfusion may increase the risks to you and the babies." D) "Lactation should be delayed until the "real milk" is secreted." The correct answer is A: "Nursing will help contract the uterus and reduce your risk of bleeding." 42. The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure? A) Place pillows under the knees B) Use elastic stockings continuously C) Encourage range of motion and ambulation D) Massage the legs twice daily The correct answer is C: Encourage range of motion and ambulation 43. The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3 day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the health care provider immediately? A) 3 episodes of vomiting in 1 hour B) Periodic crying and irritability C) Vigorous sucking on a pacifier D) No measurable voiding in 4 hours The correct answer is D: No measurable voiding in 4 hours 44. Which response by the nurse would best assist the chemically impaired client to deal with issues of guilt? A) "Addiction usually causes people to feel guilty. Don’t worry, it is a typical response due to your drinking behavior." B) "What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?"C) "Don’t focus on your guilty feelings. These feelings will only lead you to drinking and taking drugs." D) "You’ve caused a great deal of pain to your family and close friends, so it will take time to undo all the things you’ve done." The correct answer is B: "What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?"