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NESI NURSING PRACTICE TESTS FOR 2021

The nurse is caring for a client who is two days postoperative. Which observation should alert the nurse to call the Rapid Response Team (RRT)? Return to Overview 99% Correct Bravo! Let's review... your results from 3/1/2021 at 1:59 pm EST Incorrect Correct Fresh bleeding noted on abdominal surgical wound dressing. Pulse change from 85 to160 beats/minute lasting more than 10 minutes. Temperature of 103.1 F and white blood cell (WBC) count of 16,000 mm3. 3/21/2021 HESI https://hesi-preparation-suite.elsevier.com/#/hesiPracticeTestResults/1388772/1096J1FX8H7 2/56 Rationale The RRT should be called to intervene for a client with an acute life-threatening change, such as a pulse change resulting in tachycardia for a prolonged time in a post-operative client. A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further? Rationale Any nasal discharge following a head injury should be evaluated to determine the presence of cerebral spinal fluid which would indicate a tear in the dura making the client susceptible to meningitis. The nurse is providing instructions about log rolling to a client who returns to the postoperative unit after a lumbar laminectomy. Which explanation should the nurse give the client about this technique? Weakness, diaphoresis, complaints of feeling faint. BP 100/56 mm Hg. A scalp laceration oozing blood. Serosanguineous nasal drainage. Headache rated "10" on a 0-10 scale. Dizziness, nausea and transient confusion. Helps to minimize pain and anxiety. Maintains correct spinal alignment to protect the surgical area. [Show More]

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