Hesi Exit Rn 2022 V3 160 Questions Exam

1. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer’s solution at 75 mL/hour IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client’s heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the finding to the surgeon. Which action should the nurse implement first? a. Measure and document the client’s urinary output. b. Request the client’s reserved unit if packed red blood cells. c. Prepare the placement of a central venous catheter. d. Increase the infusion rate of Lactated Ringer’s solution. 2. an adult male who fell 20 feet from the roof of this home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). the nurse notes that the suction control chamber is bubbling at the - 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? a. Add sterile water to the suction control chamber. b. Give blood from the collection chamber as autotransfusion c. Manipulate blood in tubing to drain into chamber. d. Increase wall suction to eliminate fluctuation in water seal.