HESI RN
HESI 799 RN Exit Exam
1. A client with chronic kidney disease (CKD) is admitted with hyperkalemia. Which assessment finding is most concerning?
- A. Bradycardia
- B. Muscle weakness
- C. Peaked T waves on the ECG
- D. Decreased deep tendon reflexes
Correct answer: C
Rationale: The correct answer is C: Peaked T waves on the ECG. In hyperkalemia, elevated potassium levels can affect the heart's electrical activity, leading to changes on the ECG such as peaked T waves. This finding is concerning as it can progress to serious cardiac arrhythmias, including ventricular tachycardia and fibrillation. Bradycardia (choice A) and decreased deep tendon reflexes (choice D) are not typically associated with hyperkalemia. While muscle weakness (choice B) can occur in hyperkalemia due to its effect on neuromuscular function, the most concerning assessment finding indicating the need for immediate intervention in this scenario is peaked T waves on the ECG.
2. Sublingual nitroglycerin is administered to a male client with unstable angina who complains of crushing chest pain. Five minutes later, the client becomes nauseated, and his blood pressure drops to 60/40 mm Hg. Which intervention should the nurse implement?
- A. Administer a second dose of nitroglycerin.
- B. Infuse a rapid IV normal saline bolus.
- C. Begin external chest compressions.
- D. Give a PRN antiemetic medication.
Correct answer: B
Rationale: The correct intervention in this situation is to infuse a rapid IV normal saline bolus. The client's drop in blood pressure to 60/40 mm Hg after nitroglycerin administration indicates hypotension, which may suggest a right ventricular infarction. Normal saline bolus helps to increase intravascular volume, improve cardiac output, and support blood pressure. Administering a second dose of nitroglycerin would further decrease blood pressure. External chest compressions are not indicated as the client's heart is still beating, and there is no indication for CPR. Giving an antiemetic medication is not the priority in this situation where hypotension is the main concern.
3. A client with chronic kidney disease (CKD) is scheduled for hemodialysis. Which laboratory value should the nurse report to the healthcare provider before the procedure?
- A. Serum potassium of 5.5 mEq/L
- B. Hemoglobin of 10 g/dl
- C. Potassium of 6.0 mEq/L
- D. Blood glucose of 200 mg/dl
Correct answer: C
Rationale: The correct answer is C: Potassium of 6.0 mEq/L. A potassium level of 6.0 mEq/L is dangerously high in a client with CKD, and it should be reported before hemodialysis to prevent cardiac complications. High potassium levels can lead to life-threatening arrhythmias. Choices A, B, and D are not the most critical values to report before hemodialysis. While a serum potassium level of 5.5 mEq/L is slightly elevated, it is not as urgent as a level of 6.0 mEq/L in this context. Hemoglobin of 10 g/dl and blood glucose of 200 mg/dl are important parameters to monitor but are not as immediately concerning before hemodialysis compared to a high potassium level.
4. The nurse needs to add a medication to a liter of 5% Dextrose in Water (D5W) that is already infusing into a client. At what location should the nurse inject the medication?
- A. Medication port
- B. IV drip chamber
- C. Y-site connector
- D. At the hub of the IV catheter
Correct answer: A
Rationale: The correct answer is the medication port. When adding medication to an already infusing IV solution, it should be done through the medication port to ensure direct delivery into the bloodstream without interrupting the primary IV line. Injecting the medication into the IV drip chamber, Y-site connector, or at the hub of the IV catheter can lead to dilution, inaccurate dosing, or potential blockages in the IV line, which can compromise the effectiveness of the medication and patient safety.
5. An older female client tells the nurse that her muscles have gradually been getting weaker over time. What is the best initial response by the nurse?
- A. Explain that this is an expected occurrence with aging.
- B. Observe the lower extremities for signs of muscle atrophy.
- C. Review the medical record for recent diagnostic test results.
- D. Ask the client to describe the changes that have occurred.
Correct answer: D
Rationale: The best initial response by the nurse should be to ask the client to describe the changes that have occurred. This open-ended question allows the nurse to gather valuable information directly from the client, aiding in assessing the situation accurately and formulating an appropriate care plan. Choice A is incorrect as assuming muscle weakness is an expected occurrence with aging without further assessment may overlook potential underlying issues. Choice B is premature as it jumps straight to physical examination without first gathering subjective data. Choice C is unnecessary at this point as reviewing diagnostic test results should come after initial assessment and data collection from the client.
Similar Questions
Access More Features
HESI RN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $69.99
HESI RN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $149.99