Question

A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing plan of care?

Answer 1

Correct Answers:

Assess the pin sites for signs of infection.

Rationale :

🔷 Infection control is a top priority in skeletal traction due to the use of pins inserted through the skin and bone.

🔷 Pin site infection can lead to osteomyelitis or systemic infection if not detected early.

🔷 Daily inspection for redness, drainage, or foul odor is essential to intervene promptly.

🔷 Circulation and neurovascular checks are also critical but pin site care specifically prevents a direct complication of traction.

🔷 Proper aseptic technique during care minimizes risk.

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Answer 2

Correct Answers:

A grandson and his new dog recently visited.

Rationale :

🔶 Exposure to a new allergen such as pet dander is a common trigger for eczema flare-ups.

🔶 This external environmental factor is often overlooked but critical in atopic dermatitis exacerbation.

🔶 Dogs can carry allergens like dander or even irritants from outside.

🔶 This trigger can be confirmed by reviewing the timing of symptom onset relative to the visit.

🔶 Identifying and removing triggers is a key part of eczema management.

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Answer 3

Correct Answers:

Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.

Rationale :

💠 A heart rate of 140 and respiratory rate of 26 post-thoracotomy suggests hypoxia or respiratory compromise.

💠 Thoracotomy can reduce lung expansion, increasing risk of atelectasis or pneumonia.

💠 High-flow oxygen via a non-rebreather mask ensures adequate oxygen delivery during the critical post-op period.

💠 Pulse oximetry monitors response and ensures saturation stays above safe thresholds.

💠 Pain management and fluids are important but not as urgent as oxygenation.

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Answer 4

Correct Answers:

Uneven hair distribution.

Rationale :

🟡 Poor arterial circulation causes decreased nutrient and oxygen supply to the lower limbs.

🟡 Hair follicles are highly sensitive to ischemia, so uneven or sparse hair indicates reduced perfusion.

🟡 This is a classic finding in peripheral arterial disease (PAD).

🟡 Other signs may include cool extremities, delayed capillary refill, and weak pulses.

🟡 Monitoring for progressive limb ischemia is essential in PAD clients.

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Answer 5

Correct Answers:

Notify the healthcare provider of the client's medication history.

Rationale :

🔴 The client’s use of heparin increases their risk for perioperative hemorrhage.

🔴 Promptly notifying the provider ensures a reassessment of bleeding risk and surgical planning.

🔴 Holding or reversing anticoagulation may be needed before proceeding.

🔴 Documenting and communicating current medications is a safety-critical action pre-op.

🔴 This also aids in determining if labs like aPTT or platelet counts are necessary before surgery.

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Answer 6

Correct Answers:

Monitor urine and stool for occult blood regularly.

Rationale :

🟣 Platelet count of 25,000/mm³ indicates severe thrombocytopenia, placing the client at risk for spontaneous bleeding.

🟣 Occult bleeding may be the first sign of hemorrhagic complications.

🟣 Urine and stool testing can detect hidden blood loss, prompting early intervention.

🟣 This approach supports bleeding precautions and is non-invasive.

🟣 Monitoring for signs of internal bleeding is more critical than external bruising in this stage.

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Answer 7

Correct Answers:

100

Rationale :

🔵 Total volume: 2 liters = 2000 mL.

🔵 Time = 20 hours

🔵 Infusion rate = Volume ÷ Time = 2000 mL ÷ 20 hr = 100 mL/hr

🔵 Programming the IV pump with accurate rate calculation ensures safe and effective fluid delivery.

🔵 Always verify units (mL/hr) and round per institution policy if needed.

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Answer 8

Correct Answers:

Hypovolemia and electrocardiographic (ECG) changes.

Rationale :

⚪ The diuretic phase of AKI involves massive fluid loss as the kidneys recover function.

⚪ This leads to risk of hypovolemia and electrolyte imbalances, especially potassium.

⚪ ECG monitoring is essential due to potential arrhythmias from hypokalemia or hyperkalemia.

⚪ Early signs of volume depletion include hypotension, tachycardia, and dizziness.

⚪ Monitoring labs and ECG protects from life-threatening complications.

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Answer 9

Correct Answers:

Eating patterns of dietary intake.

Rationale :

🟥 Chronic pancreatitis pain is often related to dietary triggers, such as fatty meals.

🟥 Understanding meal patterns helps in identifying foods that exacerbate pain.

🟥 Many clients benefit from low-fat, high-protein, small frequent meals.

🟥 Assessing timing of pain after eating helps tailor nutritional recommendations.

🟥 Nutritional management is integral to long-term control of pancreatitis symptoms.

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Answer 10

Correct Answers:

Platelet count.

Rationale :

◼ Petechiae and ecchymosis are hallmark signs of thrombocytopenia, not anemia.

◼ Platelets are responsible for clotting, and low counts increase bleeding risk.

◼ Assessment of platelet count helps diagnose and monitor bleeding disorders.

◼ This information guides treatment decisions such as platelet transfusions or bleeding precautions.

◼ It's a critical lab in patients with unexplained bruising or bleeding.

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Hesi RN Adult II D446 Exam

No.

1 :
A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing plan of care?

2 :
During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

4 :
The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of compromised peripheral arterial circulation of the lower extremity?

6 :
A client with leukemia is receiving chemotherapy. The nurse observes the client is weak, pale, and febrile. After reviewing the client's most recent laboratory results which reveals a platelet count of 25,000/mm3 (25 x 10^9/L), which intervention should the nurse include in the plan of care?

7 :
A client receives a prescription for 2 liters of lactated Ringer's IV to be infused over 20 hours. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

8 :
A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor?

9 :
The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

10 :
The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?

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Hesi RN Adult II D446 Exam

No.

1 : A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing plan of care?

2 : During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

4 : The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of compromised peripheral arterial circulation of the lower extremity?

6 : A client with leukemia is receiving chemotherapy. The nurse observes the client is weak, pale, and febrile. After reviewing the client's most recent laboratory results which reveals a platelet count of 25,000/mm3 (25 x 10^9/L), which intervention should the nurse include in the plan of care?

7 : A client receives a prescription for 2 liters of lactated Ringer's IV to be infused over 20 hours. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

8 : A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor?

9 : The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

10 : The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?

1 :
A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing plan of care?

2 :
During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

4 :
The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of compromised peripheral arterial circulation of the lower extremity?

6 :
A client with leukemia is receiving chemotherapy. The nurse observes the client is weak, pale, and febrile. After reviewing the client's most recent laboratory results which reveals a platelet count of 25,000/mm3 (25 x 10^9/L), which intervention should the nurse include in the plan of care?

7 :
A client receives a prescription for 2 liters of lactated Ringer's IV to be infused over 20 hours. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

8 :
A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor?

9 :
The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

10 :
The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?