The nurse instructs a client to use 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?

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HESI RN Exit Exam 2024 Quizlet Capstone Questions

Question 1 of 5

The nurse instructs a client to use 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?

Correct Answer: B

Rationale: The correct action for the nurse to take in response to the return demonstration of using an incentive spirometer is to remind the client to cough after using the device. Coughing helps clear secretions from the lungs and promotes lung expansion. Instructing the client to inhale more deeply (Choice A) is not necessary as the primary focus after using the spirometer is to clear secretions. Praising the client for correct usage (Choice C) is positive but does not address the essential step of coughing. Suggesting increasing the frequency of spirometer use (Choice D) is not the immediate action needed after the demonstration.

Question 2 of 5

After a spider bite on the lower extremity, a client is admitted to treat an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider?

Correct Answer: C

Rationale: All of the above findings should be reported to the healthcare provider for prompt evaluation and treatment. Swollen lymph nodes in the groin indicate regional lymphatic involvement, a core body temperature of 100.5°F suggests a mild fever response, and an elevated white blood cell count indicates an ongoing infection process. These findings collectively point towards the spread of infection and require immediate attention to prevent further complications.

Question 3 of 5

A client with hyperthyroidism is admitted to the postoperative unit after a subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse?

Correct Answer: C

Rationale: A total calcium level of 5.0 mg/dL is critically low and indicates possible hypocalcemia, a common complication after thyroid surgery. This condition can lead to tetany and requires immediate intervention. Blood glucose within normal range, sodium, and potassium levels are not indicative of an immediate postoperative complication like hypocalcemia in this case.

Question 4 of 5

A combination multi-drug cocktail is being considered for an asymptomatic HIV-infected client with a CD4 cell count of 500. Which nursing assessment of the client is most crucial in determining whether therapy should be initiated?

Correct Answer: C

Rationale: The most crucial nursing assessment in determining whether therapy should be initiated for an asymptomatic HIV-infected client with a CD4 cell count of 500 is the client's willingness to comply with complex drug schedules. Adherence to antiretroviral therapy is essential for its effectiveness. Assessing the client's willingness and ability to comply with the complex medication regimen is crucial to ensure successful treatment and prevent drug resistance. Choices A, B, and D, although important in the overall care of the client, are not as crucial as assessing the client's willingness to adhere to the prescribed drug regimen.

Question 5 of 5

A client with a history of asthma reports using an albuterol inhaler more frequently than prescribed. Which action should the nurse take first?

Correct Answer: C

Rationale: Increased use of a rescue inhaler like albuterol may indicate worsening asthma symptoms. The nurse should first assess the client's respiratory status to determine the severity of the issue and the next steps in care. Option A is not the first action because assessing the client's condition should precede notifying the healthcare provider. Option B, scheduling a pulmonary function test, is not the priority as immediate assessment of the client's respiratory status is crucial. Instructing the client to decrease inhaler use should come after assessing the client's condition to ensure the appropriate intervention.

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