Exam (elaborations) HESI RN FUNDAMENTALS

HESI RN FUNDAMENTALS The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significantgrandution. The wound has a gauze dressing covering the area. What action should the nurse implemented? A) Apply a hydro gel (Duaderm) dressing B) Increase the frequency of the dressing changes. C) Replace the gauze with transparent dressing. D) Leave the dressing off until consulting with the healthcare provider. The healthcare provider prescribes haloperidol (Haldol) 1.5mg twice daily for a client with Tourette’s syndrome. Thedrug is available in a solution labeled, “2 mg/ml.” How many ml should the nurse administer? (Round to the nearest hundredth.) 0.75 A male client with limited mobility is discharged with home health services. When the home health nurse arrives, theclient asks what he can do for the swelling in his legs. Which should nurse implement? A) Encourage the client to take short walks around the block. B) Explain the need to keep the head of the bed elevated. C) Advise the client to dangle his feet during meals and before bedtime. D) Instruct the client to flex both of his feet several times a day. The home care nurse is teaching a client how to change the dressing on a new venous stasis ulcer. The client has a history of a deep vein thrombosis and is allergic to latex. When removing the adhesive bandages, the nurse observes skin redness surrounding the draining wound. What action should the nurse implemented? A) Replace dressing with cotton pads and silk tape. B) Measure and compare ankle-brachial pressure index. C) Obtain sample of the drainage for culture. D) Apply an antibiotic ointment to the wound. The nurse measures the client’s blood pressure (BP) and notes that it is significantly higher than the previous reading. What should the nurse do next? (Select all that apply.) A) Retake the client’s blood pressure in the opposite arm. B) Ask another nurse to assist in assessing for an apical-radial pulse deficit. C) Assign the unlicensed assistive personal to recheck the BP in an hour. D) Immediately take 2 more readings on the same arm. E) Determine the client’s activity and feelings prior to the BP measurement