A 4-year-old child is returned to the room following a tonsillectomy and adenoidectomy. Which of the following assessments would require the nurse's immediate attention?

Questions 82

HESI RN

HESI RN Test Bank

HESI 799 RN Exit Exam Capstone Questions

Question 1 of 5

A 4-year-old child is returned to the room following a tonsillectomy and adenoidectomy. Which of the following assessments would require the nurse's immediate attention?

Correct Answer: A

Rationale: In a post-tonsillectomy and adenoidectomy patient, frequent swallowing is a crucial assessment that requires immediate attention by the nurse. Frequent swallowing can indicate bleeding, a complication that needs urgent intervention. Coughing may be expected due to irritation from the surgery but is not as concerning as potential bleeding. Slow breathing and tachycardia are not typically immediate concerns following this type of surgery.

Question 2 of 5

A nurse is caring for a 73-year-old male client with Alzheimer's disease. Which action should the nurse take to enhance the client's nutritional intake?

Correct Answer: B

Rationale: Offering frequent snacks of foods the client enjoys is the most appropriate action to enhance the nutritional intake of a client with Alzheimer's disease. This approach helps to ensure that the client receives an adequate amount of nutrients throughout the day, especially when larger meals might be challenging for individuals with Alzheimer's. Encouraging large meals in one sitting (Choice A) may overwhelm the client and lead to decreased food intake. While foods high in fiber (Choice C) are beneficial for digestion, the primary focus should be on providing foods the client enjoys to increase intake. Discouraging eating late at night (Choice D) is not directly related to enhancing nutritional intake in this scenario.

Question 3 of 5

The nurse is caring for a client who is post-op after a hip replacement. Which of the following nursing actions is most appropriate to prevent dislocation of the hip?

Correct Answer: B

Rationale: Using an abduction pillow between the client's legs is the most appropriate nursing action to prevent dislocation after hip replacement surgery. An abduction pillow helps maintain proper alignment and prevents the hip from dislocating. Placing the client in a high Fowler's position (Choice A) or encouraging them to sit upright for long periods (Choice D) may not provide the necessary support and stability needed to prevent hip dislocation. Encouraging the client to cross their legs while sitting (Choice C) can increase the risk of hip dislocation and should be avoided.

Question 4 of 5

A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The appropriate response of the nurse should be which of these statements?

Correct Answer: D

Rationale: The correct answer is D: "I need to get the client's written consent before I release any information to you." In this scenario, the nurse must obtain the client's written consent before disclosing any information to the social worker. This process ensures compliance with privacy laws like HIPAA, which are designed to protect client confidentiality. Choice A is incorrect because it does not address the need for consent. Choice B is incorrect as it is unprofessional and does not focus on obtaining consent. Choice C is incorrect as it suggests information can be shared without consent, which goes against privacy laws.

Question 5 of 5

A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse?

Correct Answer: B

Rationale: In this scenario, it is more appropriate to assign a stable client, such as the one with a myocardial infarction who is free from pain and dysrhythmias, to a nurse who lacks specialized critical care experience. This client's condition is relatively stable and does not require immediate critical interventions. Choices A, C, and D involve clients with more complex and critical conditions that would be better managed by a nurse with specialized critical care training. Choice A involves a client on a Dopamine drip with frequent vital sign monitoring, Choice C has a client with a tracheotomy in respiratory distress, and Choice D describes a client with a pacemaker experiencing intermittent capture, all of which require a higher level of critical care expertise.

Access More Questions!

HESI RN Basic


$89/ 30 days

HESI RN Premium


$150/ 90 days

Similar Questions