Nurs 310 HESI Review exam prep with complete solution

Nurs 310 HESI Review exam prep with complete solution A 75 -year -old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis treatments, stating that death is i nevitable, but the client is disoriented and will not sign a DNR directive. What is the priority nursing intervention? Review the client's most recent laboratory reports. Refer the client and family members for hospice care. Notify the hospital ethics committee of the client situation. Determine who is legally empowered to make decisions. - =Determine who is legally empowered to make decisions. A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which type of foo ds should the nurse recommend that the client select from the hospital menu? Low fat and low sodium foods. Combination of plant proteins to provide essential amino acids. Limited complex carbohydrates and fiber. Increased amount of vitamin C and beta carotene rich foods. - =Combination of plant proteins to provide essential amino acids. A macrobiotic diet is high in whole -grain cereals, vegetables, sea vegetables, beans, and vegetarian soups, and the client needs essential amino acids to provide complete proteins to heal the infected wound. Although a macrobiotic diet contains no source of animal protein, essential amino acids should be obtained by combining plant (incomplete) proteins to provide complete (all esse ntial amino acids) proteins (B) for anabolic processes. (A, C, and D) do not provide the client with food choices consistent with a macrobiotic diet and protein needs. The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first? Check for a blood return. Reposition the cl ient's arm. Remove the IV site dressing. Flush the lock with saline. - =Reposition the client's arm. If the client's elbow is bent, the IV may be unable to infuse, resulting in an obstruction alarm, so the nurse should first attempt to reposition the c lient's arm to alleviate any obstruction What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? Maintain in a lateral position using protective wrist and vest devices. Position prone with a small pillow below the diaphragm. Raise the head and knee gatch when lying in a supine position. Transfer into a wheelchair close to the nurse's station for observation. - =Position prone with a small pillow below the diaphragm. What intervention should th e nurse include in the plan of care for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency? Check capillary refill of toes on lower extremity with Unna's paste boot. Apply dressing to wound area before applying the Unna's paste boot. Wrap the leg from the knee down towards the foot. Remove the Unna's paste boot q8h to assess wound healing. - =Check capillary refill of toes on lower extremity with Unna's paste boot. Which nursing intervention is most beneficial in reducing the risk of urosepsis in a hospitalized client with an indwelling urinary catheter? Ensure that the client's perineal area is cleansed twice a day. Maintain accurate documentation of the fluid intake and output. Encourage frequent ambulation if allowed or regular turning if on bedrest. Obtain a prescription for removal of the catheter as soon as possible. - =Obtain a prescription for removal of the catheter as soon as possible. The best int ervention to reduce the risk for urosepsis (spread of an infectious agent from the urinary tract to systemic circulation) is removal of the urinary catheter as quickly as possible