2023/2024 NGN Exit HESI (Answered)

2023/2024 NGN Exit HESI (Answered) The nurse identifies an electrolyte imbalance, a weight gain of 4.4lbs in 24 hours and an elevated central venous pressure for a pt with full thickness burns. Which intervention should the nurse implement? Auscultate for irregular heart rate. A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presenting with which symptoms require the most immediate intervention by the nurse? Chest discomfort one hour after consuming a large spicy meal. Which self care measure is most important to include in the plan of care of a pt recently diagnosed with type 2 diabetes mellitus? blood glucose monitoring. In assessing a pt with type 1 diabetes mellitus, the nurse notes that the client's respirations have changed from 16 breaths/min with a normal depth to 32 breaths/min and deep. And the pt has become lethargic. Which assessment data should the nurse obtain next? blood glucose An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9 is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of ketoacidosis? had a cold and ear infection for the past two days. The nurse assesses a pt who had bilateral total knee replacements four hours ago. The nurse notes that the dressing on the right knee is saturated with serosanguineous drainage. What action should the nurse implement? Determine if the wound drainage device is functioning correctly. A pt with chronic kidney disease has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patient? Auscultation of a thrill on the left forearm A client with urge incontinence was treated with onabotulinumtoxinA injections and is now experiencing urinary retention. Which action should the nurse include in the client's plan of care? Remind the pt to practice pelvic floor exercises regularly. A pt is admitted with a dx of urolithiasis. Which finding is most important for the nurse to report to the healthcare provider? Hematuria that is beginning to turn pink The nurse is evaluating the chest drainage system of a patient with a chest tube inserted to treat a left hemothorax. Which finding requires intervention by the nurse? cont. bubbling in the water seal chamber The nurse is caring for a pt who has chronic obstructive pulmonary disease and chest pain related to a recent fall. What nursing intervention requires the greatest caution when caring for a pt with COPD? administering narcotics for pain relief The nurse instructs a pt in use of an incentive spirometer. The client performs a return demonstration as seen in the video. Which action should the nurse take in response to the return demonstration? Remind the pt to cough using the spirometer The healthcare provider prescribes a sepsis protocol for a pt with organ failure caused by a ruptured appendix. Which intervention is most important for the nurse to include in the plan of care? Maintain strict intake and output A pt diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention? Allopurinol An adult client is admitted to the ED after falling from a ladder. While waiting to have a CT scan, the client requests something for a severe headache. When the nurse offers a prescribed dose of acetaminophen, the pt asks for something stronger. Which intervention should the nurse implement? Explain the reason for using only non-narcotics The nurse is providing care for a pt with severe peripheral arterial disease. The pt reports a history of rest ischemia, with leg pain that occurs during the night. Which action should the nurse take in response to this finding? Offer cold packs when pain occurs When taking a health history, which information collected by the nurse correlates most directly to a diagnosis of chronic peripheral arterial insufficiency? History of intermittent claudication the nurse assesses a pt being treated for Herpes Zoster (Shingles). Which assessments should the nurse include when evaluating the effectiveness of treatment? SATA