Hesi Rn Fundamental NSG

Correct Answer:

C. Hematocrit

Explanation:

Melena, or black, tarry stools, suggests gastrointestinal bleeding, typically from the upper GI tract, where blood is digested and turns black. This bleeding can lead to a drop in red blood cells and hemoglobin as the blood is lost, which in turn causes a decrease in hematocrit levels. Monitoring hematocrit is important because it reflects the percentage of red blood cells in the blood and can indicate blood loss, including in the case of melena. A decrease in hematocrit will show that the body is losing blood, potentially due to an ongoing GI bleed.

Why the Other Options Are Incorrect:

A. White blood cell count (WBC): While an elevated WBC count may suggest an infection or inflammation, it is not directly related to the presence of melena or bleeding. It is not the most helpful laboratory test in the case of GI bleeding.

B. Blood urea nitrogen (BUN): Although BUN can increase with gastrointestinal bleeding due to the digestion and absorption of blood, it is not the most immediate indicator of blood loss when compared to hematocrit. BUN can also be influenced by other factors like kidney function and hydration status.

D. Glucose: Glucose levels are unrelated to gastrointestinal bleeding and melena. They are more relevant in conditions like diabetes or in assessing for hypoglycemia or hyperglycemia, but not for melena.

Correct Answer:

Ask the client to describe the pain.

Explanation:

Assessing quality of pain involves descriptive terms like "burning," "stabbing," "throbbing," or "aching." The only way to gather this information is by asking the client directly to describe what the pain feels like, making this the most accurate method to assess pain quality.

Why Other Options are Wrong:

Provide a numeric pain scale.

This assesses intensity, not quality, of pain.

Observe body language and movement.

This is useful for clients unable to verbalize pain, but it provides indirect signs—not a description of pain quality.

Identify effective pain relief measures.

This helps guide treatment but does not assess or clarify what the pain actually feels like to the client.

Correct Answer:

Use a moist towel as a skin barrier.

Explanation:

To prevent burns and skin damage, a barrier such as a moist towel should always be placed between the heat source and the client’s skin. This is a standard nursing intervention during heat therapy to protect tissue integrity.

Why Other Options are Wrong:

Obtain a prescription for heat application.

While some facilities may require provider orders, in many cases, nurses can implement non-invasive comfort measures like heat therapy under standard protocols. This is not the most immediate or practical action in this scenario.

Assess skin every 30 minutes after application.

Assessment is important, but waiting 30 minutes could be too long to detect early signs of burns or redness. Initial focus should be on prevention through proper application technique, such as using a barrier.

Demonstrate use of temperature control.

This is helpful if the client is self-administering therapy at home, but it does not address the immediate safety concern—preventing burns during nurse-administered therapy.

Correct Answer:

B. Crepitus is always abnormal and should be followed up with a more detailed assessment.

Explanation:

Crepitus, which refers to a crackling or popping sensation felt under the skin, often indicates the presence of air or gas under the skin, typically due to trauma or an underlying injury. It is never considered normal and warrants further investigation. In this case, even though the crepitus is localized to a small area, it is an abnormal finding that should not be ignored. The most likely cause could be subcutaneous emphysema, which can occur due to trauma (such as rib fractures, lung injury, or a surgical procedure) or infection. A more detailed assessment and imaging (such as a chest x-ray or CT scan) are needed to determine the cause and extent of the issue.

Why the Other Options are Incorrect:

A. Trapped subcutaneous air causing crepitus will be absorbed, so the finding is not significant: While subcutaneous air from trauma or other causes may eventually be reabsorbed by the body, it is not safe to assume that the finding is not significant without further evaluation. Crepitus should always be investigated to rule out potential serious underlying conditions, such as fractures, pneumothorax, or infections.

C. Since this client has only a small area of crepitus, it probably is not a significant finding: Size does not dictate the seriousness of the condition. Even a small area of crepitus could signal a potentially serious issue, such as a rib fracture or lung injury. Further assessment is needed to determine the cause.

D. Since a fractured rib often creates crepitus, a chest x-ray should be scheduled immediately: While a fractured rib can create crepitus, this is not the only possible cause, and a chest x-ray should be considered based on the full clinical picture. Further evaluation should be done to assess whether a rib fracture, pneumothorax, or another issue is present. However, a chest x-ray would be part of a more comprehensive assessment following the recognition of an abnormal finding like crepitus.

Correct Answer:

An older adult with a right hip fracture.

Explanation:

Clients with hip fractures are typically immobile due to pain and risk of further injury. Moving such clients to the toilet can increase the risk of falls or worsen the fracture. Therefore, using a bedpan ensures both safety and hygiene during elimination.

Why Other Options are Wrong:

An older adult with left sided weakness.

This client may still be able to use a bedside commode or toilet with assistance. Weakness doesn’t necessarily mean full immobility.

An adult client with enuresis.

Enuresis refers to involuntary urination, often during sleep. These clients usually don't require a bedpan, as their issue is not related to mobility.

An adult client with polyuria.

Frequent urination (polyuria) doesn’t inherently mean the client is immobile. These clients can often toilet independently or with minimal assistance.

Correct Answer:

B. Auscultate the client's breath sounds.

Explanation:

The client's symptoms—awakening at night with cold sweats, difficulty breathing, and a racing heart—are concerning for acute heart failure exacerbation or a possible acute pulmonary edema event. The most immediate and relevant assessment the nurse should make is to auscultate the client’s breath sounds. This will help identify signs of fluid overload in the lungs, such as crackles or rales, which are common in heart failure. Early identification of pulmonary congestion or edema allows for timely intervention to prevent further complications.

Why the Other Options are Incorrect:

A. Ask about any environmental allergies: While allergies can cause respiratory symptoms, the client's symptoms (difficulty breathing, cold sweats, and racing heart) are more indicative of an acute cardiovascular event. Asking about allergies is not the priority in this situation, as it does not address the most immediate concern.

C. Assess the elasticity of the client's skin: Skin elasticity is typically assessed to gauge hydration status or possible malnutrition, but it does not directly relate to the cardiovascular issues the client is presenting with. The priority assessment in this case is to determine if there is a cardiovascular cause for the client's symptoms.

D. Measure the client's core temperature: A temperature assessment is important if there is suspicion of infection or fever, but the symptoms described (cold sweat, difficulty breathing, and racing heartbeat) are more consistent with heart failure exacerbation, making auscultation of breath sounds more critical in this situation.

Correct Answer:

Place the client in a side-lying position.

Explanation:

Positioning an unconscious client in a side-lying position during oral care helps prevent aspiration by allowing secretions or fluids to drain from the mouth instead of entering the airway. This is a critical safety measure.

Why Other Options are Wrong:

Avoid contact with the roof of the mouth.

There is no need to avoid this area unless contraindicated. This does not address aspiration risk, which is the main concern.

Don sterile gloves prior to performing oral care.

Sterile gloves are not necessary for routine oral care. Clean gloves are sufficient.

Raise the head of bed to 45 degrees.

This helps with drainage but is not as effective as side-lying for aspiration prevention in an unconscious client.

Correct Answer:

C. Compare muscle strength bilaterally.

Explanation:

To gather additional data about the muscular atrophy observed in the right thigh and calf, the nurse should compare muscle strength bilaterally. This will help determine whether the muscle weakness or atrophy is limited to the right side or if there is also weakness or atrophy on the left side. A difference in strength between the two sides can give insight into the severity of the muscle loss and help differentiate between causes, such as neurological issues or local muscular problems.

Why the Other Options are Incorrect:

A. Measure degree of skin elasticity: Skin elasticity may be useful in evaluating hydration status or skin condition but does not provide information about muscular atrophy or muscle strength, which is the primary concern in this scenario.

B. Obtain vital signs and oxygen saturation: While vital signs and oxygen saturation are important in assessing overall health, they do not directly assess the extent or cause of muscle atrophy. They are not helpful for understanding the specific issue of muscular atrophy.

D. Calculate the body mass index (BMI): BMI is a general measurement used to assess overall body weight in relation to height. Although it may provide insight into overall health and nutritional status, it does not give specific information about muscle mass or muscle strength. Therefore, it is not the most relevant action to take in this case.

Correct Answer:

Obtain the specimen from the client’s current bowel movement.

Explanation:

An occult blood test is specifically designed to detect hidden (not visible) blood in the stool. The color or appearance of the stool doesn’t need to show visible signs of bleeding. Testing a normal-appearing stool is appropriate and in fact expected when checking for occult blood.

Why Other Options are Wrong:

Contact the healthcare provider before obtaining the specimen.

There is no need to notify the provider as long as a stool sample was requested. The nurse should proceed with the specimen collection as ordered.

Withhold specimen collection until tarry black stool is observed.

Waiting for visible signs of blood contradicts the purpose of occult testing. Tarry stool suggests obvious GI bleeding, which does not require occult testing.

Wait to obtain the specimen until observable blood is present.

Again, this defeats the purpose of an occult blood test, which is to identify non-visible blood in the stool.