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BSN 266 : HESI (CIRRHOSIS CASE STUDY) COMPLETE & VERIFIED EXAM GRADED A+ A client who underwent cardiac stent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which action shou$17.89
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BSN 266 : HESI (CIRRHOSIS CASE STUDY) COMPLETE & VERIFIED EXAM GRADED A+ A client who underwent cardiac stent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which action shou
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Course
BSN 266 : HESI
Institution
BSN 266 : HESI
BSN 266 : HESI (CIRRHOSIS CASE STUDY) COMPLETE &
VERIFIED EXAM GRADED A+
A client who underwent cardiac stent placement four days ago arrives to the
emergency department reporting a sudden onset of chest pressure and
shortness of breath. Which action should the nurse take next?
a. Listen for e...
A client who underwent cardiac stent placement four days ago arrives to the
emergency department reporting a sudden onset of chest pressure and
shortness of breath. Which action should the nurse take next?
a. Listen for extra heart sounds, murmurs, and rhythm with the bell of
the stethoscope.
b. Evaluate upper and lower extremities for perfusion, pulse volume,
and pitting edema.
c. Verify troponin level assessments are scheduled every 3-6 hours
for a series of three.
d. Obtain a 12- lead electrocardiogram and begin continuous cardiac
monitoring.
D
A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of
weakness and palpitations. Which finding should the nurse recognize as a
possible complication?
a. anxiety and sighing
b. myalgia in wrists and hands
c. hyperactive bowel sounds
d. dark yellow urine
45. A client with draining skin lesions of the lover extremity is admitted with
possible Methicillin-Resistant Staphylococcus Aureus (MRSA). Which nursing
interventions should the nurse include in the plan of care? (Select all that apply.)
a. Explain the purpose of a low bacteria diet.
b. Monitor the client's white blood cell count.
c. Send wound drainage for culture and sensitivity.
d. Use standard precautions and wear a mask.
e. Institute contact precautions for staff and visitors.
BCE
Explanation: Monitoring the client's white blood cell count can help assess the
severity
of the infection and response to treatment. Sending wound drainage for culture and
sensitivity will help identify the causative organism and guide appropriate antibiotic
therapy. Instituting contact precautions for staff and visitors will prevent the potential
spread of MRSA. A low bacteria diet is not necessary in this situation, and using
standard precautions with a mask is insufficient for preventing the spread of MRSA
46. The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a
client who was exposed to the virus eight days ago. The client is experiencing
, fever, cough and shortness of breath. Which action is most important for the
nurse to take?
a. Counsel family members to monitor for illness symptoms for 2
weeks after last contact with patient.
b. Move the client to a private room, keep the door closed, and initiate
droplet precautions.
c. Start an intravenous infusion for antiviral drug to be administered
for positive COVID-19 test results.
d. Assist the client to recall everyone possibly exposed since onset
symptoms.
B
Explanation: In order to minimize the risk of transmission of COVID-19 to other patients
and staff, it is important to isolate the client in a private room with the door closed and
initiate droplet precautions. While counseling family members, assisting the client to
recall exposed individuals, and preparing for potential antiviral treatment may be
necessary, the priority is to prevent the spread of the virus within the healthcare setting.
47. A client with multiple sclerosis has urinary retention related to sensorimotor
details. Which action should the nurse include in the client's plan of care?
a. Remind the client to practice pelvic floor (Kegel) exercises
regularly.
b. Provide a bedside commode for immediate use in the client's
discomfort.
c. Explain the need to limit intake of oral fluids to reduce client
discomfort.
d. Teach the client techniques for performing intermittent
catheterization.
D
Explanation: In a client with multiple sclerosis who is experiencing urinary retention,
teaching the client techniques for performing intermittent catheterization can help
manage their bladder issues. Pelvic floor exercises may not be as effective for
sensorimotor deficits, and limiting fluid intake is not recommended for clients with
urinary retention. Providing a bedside commode may be helpful for convenience but
does not address the root issue of urinary retention.
48. A client who has a history of hypothyroidism was initially with lethargy and
confusion. Which additional finishing warrants finding warrants the most
immediate action by the nurse?
a. Facial puffiness and periorbital edema.
b. Further decline in level consciousness.
c. Hematocrit of 30% (0.30).
d. Cold and dry skin.
B
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