The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement?

Correct Answer: B

Rationale: In this scenario, the correct action for the nurse to implement is Option B: Inform the UAP that the pillows should be removed immediately. This is the correct choice because placing pillows along the side rails during a seizure can pose a significant safety risk to the client. In the event of a seizure, the client may thrash uncontrollably and could potentially injure themselves on the pillows or become entangled in them, leading to further harm. Option A is incorrect because leaving the pillows in place without addressing the safety concern puts the client at risk. Option C is incorrect as firm padding could still pose a risk of injury during a seizure. Option D is also incorrect as padding the side rails does not address the immediate safety issue presented by the pillows. From an educational perspective, this question highlights the importance of understanding safety precautions for clients with seizure disorders. It emphasizes the nurse's role in ensuring a safe environment and providing appropriate guidance to unlicensed personnel to prevent potential harm to the client.

Correct Answer: B

Rationale: In the context of the HESI RN Exit Exam Capstone, understanding the importance of surgical hand scrub duration is crucial for maintaining aseptic technique and preventing surgical site infections. The correct answer, B) Extend scrub time to 5 minutes, is based on evidence-based practice guidelines that recommend a 5-minute scrub to effectively reduce microbial flora on the hands prior to surgery. Option A) Proceed with surgery preparation is incorrect because a 3-minute scrub is not considered sufficient to adequately reduce the microbial flora on the hands. Option C) Use an alcohol-based hand sanitizer is also incorrect because while alcohol-based sanitizers are effective in certain situations, they are not a substitute for a thorough surgical hand scrub before surgery. Option D) Scrub time depends on the type of surgery is incorrect because regardless of the type of surgery, a 5-minute hand scrub is generally recommended to ensure proper hand hygiene practices are followed consistently. Educationally, this question highlights the importance of adhering to evidence-based guidelines in healthcare settings to promote patient safety and prevent healthcare-associated infections. Understanding and following proper hand hygiene protocols is a fundamental aspect of nursing practice that directly impacts patient outcomes and quality of care.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) 75 ml/hour. To calculate the infusion rate, we need to consider the concentration of the medication in the solution. Isoproterenol is ordered at 300 mcg/hour and is diluted in D5W. To determine the mL/hour rate, we need to convert the mcg to mg (1 mcg = 0.001 mg) and then calculate the total volume of the solution. Considering the concentration of isoproterenol and the diluent, the correct calculation is as follows: 300 mcg/hour = 0.3 mg/hour 0.3 mg x 1000 mcg = 300 mcg in 1 ml So, 0.3 mg is in 1 ml of the solution. Therefore, the nurse should set the pump to 75 ml/hour to deliver the prescribed dose of isoproterenol. Now, let's analyze the other options: A) 100 ml/hour: This is incorrect because it does not consider the concentration of the medication and would result in an incorrect dosage. C) 60 ml/hour: This option is incorrect as it does not account for the correct rate of infusion needed for the prescribed dose. D) 125 ml/hour: This option is incorrect as it would result in an incorrect dosage due to not considering the concentration of the medication. Understanding medication calculations is crucial for nurses to ensure patient safety and provide accurate care. Nurses must be able to calculate infusion rates correctly to administer medications safely and effectively. Practice and proficiency in medication calculations are essential skills for nursing practice.

Correct Answer: D

Rationale: The correct follow-up question for the nurse to ask in this scenario is "D) Have you had recent cold intolerance or unusual fatigue?" This question is most appropriate because the client's symptoms (coarse hair, eyebrow changes, puffy eyes) are indicative of hypothyroidism, a condition where the thyroid gland is underactive. Cold intolerance and unusual fatigue are common symptoms of hypothyroidism, so asking about these can provide valuable information for further assessment and potential diagnosis. Option A) "Have you noticed any changes in your fingernails?" is less relevant in this context as changes in the nails are not specific to thyroid dysfunction. Option B) "Have you had any changes in weight or energy levels?" While weight gain and low energy can be seen in hypothyroidism, they are not as specific to the symptoms described by the client. Option C) "Do you have a family history of thyroid problems?" While family history can be important in assessing risk factors for thyroid disorders, the client's current symptoms are more indicative of her own thyroid status rather than her family history. In an educational context, it is crucial for nurses to understand the importance of thorough assessment and the relevance of specific questions based on presenting symptoms. This question highlights the need for critical thinking in connecting symptoms to potential underlying conditions, demonstrating the importance of holistic care and assessment in nursing practice.

Correct Answer: C

Rationale: In this scenario, the assessment finding that warrants immediate intervention by the nurse is option C) Round and tight abdomen. This finding indicates a potential complication of ascites, such as abdominal compartment syndrome, which can lead to impaired circulation, respiratory compromise, and even organ failure. Immediate intervention is crucial to prevent further deterioration of the client's condition. Option A) Capillary refill of 8 seconds is a concerning finding but is not as critical as a round and tight abdomen in this context. It may indicate issues with perfusion, but it does not directly address the immediate threat posed by a tense abdomen. Option B) Bruises on arms and legs may suggest a bleeding disorder or trauma but do not directly address the urgent issue of a round and tight abdomen. Option D) Pitting edema in lower legs is a common finding in clients with ascites and may be related to fluid retention, but it does not indicate the same level of urgency as a tense abdomen. Educationally, understanding the significance of different assessment findings in clients with ascites is crucial for nurses caring for these patients. Recognizing the signs of complications like abdominal compartment syndrome and knowing when to intervene promptly can help prevent adverse outcomes and improve patient care.