HESI RN
HESI 799 RN Exit Exam Quizlet
1. A nurse is preparing to insert a nasogastric tube (NGT) in a client. Which action should the nurse take first?
- A. Assess the client's history for nasal trauma or surgery
- B. Ask the client to cough and deep breathe.
- C. Measure the length of the tube to be inserted.
- D. Explain the procedure to the client and obtain consent.
Correct answer: D
Rationale: The correct first action for the nurse to take when preparing to insert a nasogastric tube (NGT) in a client is to explain the procedure to the client and obtain consent. It is crucial to ensure that the client is informed about the procedure, understands it, and consents to it before proceeding. Assessing the client's history for nasal trauma or surgery (Choice A) is important but can be done after obtaining consent. Asking the client to cough and deep breathe (Choice B) is not directly related to the initial step of preparing for NGT insertion. Measuring the length of the tube to be inserted (Choice C) is a necessary step but should come after explaining the procedure and obtaining consent.
2. The healthcare provider prescribes carboprost tromethamine (Hemabate) 250 mcg IM for a multigravida postpartum client who is experiencing heavy, bright red vaginal bleeding. Prior to administering this medication, which intervention should the RN implement?
- A. Give the prescribed antiemetic.
- B. Administer IV fluids.
- C. Prepare for possible blood transfusion.
- D. Monitor vital signs every 5 minutes.
Correct answer: A
Rationale: The correct answer is A. Hemabate can cause severe nausea, vomiting, or diarrhea, so administering the prescribed antiemetic can help manage these side effects. Choice B is incorrect as there is no indication in the scenario to administer IV fluids. Choice C is not the priority at this stage as the client's condition does not necessitate an immediate blood transfusion. Choice D is unnecessary every 5 minutes; monitoring vital signs should be done but not at such a high frequency.
3. An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. After starting medication therapy, the nurse notices the client has more energy, is giving away her belongings, and has an elevated mood. Which intervention is best for the nurse to implement?
- A. Support the client by telling her what wonderful progress she is making.
- B. Ask the client if she has had any recent thoughts of harming herself.
- C. Reassure the client that the antidepressant drugs are apparently effective.
- D. Tell the client to keep her belongings because she will need them at discharge.
Correct answer: B
Rationale: When a client with major depressive disorder shows signs of increased energy, giving away belongings, and an elevated mood, it could indicate a shift towards suicidal behavior. Therefore, the best intervention for the nurse is to ask the client if she has had any recent thoughts of harming herself. This is crucial to assess the client's risk for suicide and provide necessary interventions. Choices A, C, and D are incorrect because they do not address the potential risk of harm to the client and do not prioritize the immediate assessment required in this situation.
4. A school nurse is called to the soccer field because a child has a nosebleed (epistaxis). In what position should the nurse place the child?
- A. Sitting up and leaning forward
- B. Lying flat with legs elevated
- C. Lying on the side with the head slightly raised
- D. Sitting up and tilting the head back
Correct answer: A
Rationale: The child with a nosebleed (epistaxis) should be placed in a sitting position, leaning forward, to prevent blood from flowing down the throat. This position helps to control the bleeding and prevents the child from swallowing blood, which can cause nausea or vomiting. Choice B is incorrect because elevating the legs is not recommended for nosebleeds. Choice C is incorrect because lying on the side with the head slightly raised is not the optimal position for managing a nosebleed. Choice D is incorrect because tilting the head back can lead to blood flowing down the throat and potentially cause aspiration.
5. While performing a skin inspection for a female adult client, the nurse observes a rash that is well circumscribed, has silvery scales and plaques, and is located on the elbows and knees. These assessment findings are likely to indicate which condition?
- A. Tinea corporis
- B. Herpes zoster
- C. Psoriasis
- D. Drug reaction
Correct answer: C
Rationale: The correct answer is C, Psoriasis. Psoriasis commonly presents with well-circumscribed, silvery scales and plaques, typically found on extensor surfaces like elbows and knees. Tinea corporis (A) presents as a circular rash, herpes zoster (B) presents as a painful rash following a dermatomal pattern, and drug reactions (D) have variable presentations not specific to elbows and knees with silvery scales and plaques.
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