HESI RN
HESI 799 RN Exit Exam Quizlet
1. A nurse is preparing to administer a dose of digoxin (Lanoxin) to a client with heart failure. Which assessment finding requires immediate intervention?
- A. Apical pulse of 58 beats per minute
- B. Blood pressure of 110/70 mmHg
- C. Presence of a new murmur
- D. Respiratory rate of 18 breaths per minute
Correct answer: A
Rationale: An apical pulse of 58 beats per minute is concerning when administering digoxin because digoxin can further lower the heart rate, leading to bradycardia or heart block. Immediate intervention is required to prevent potential complications. A blood pressure of 110/70 mmHg is within normal range and does not require immediate intervention in this context. The presence of a new murmur may indicate valvular issues but does not directly relate to the administration of digoxin. A respiratory rate of 18 breaths per minute is also within normal limits and is not a priority concern when administering digoxin.
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. Which nursing intervention has the highest priority for a multigravida who delivered twins and is at risk for postpartum hemorrhage?
- A. Maintain cold packs on the perineum for 24 hours.
- B. Assess the client's pain level frequently.
- C. Observe for appropriate interaction with the infants.
- D. Assess fundal tone and lochia flow.
Correct answer: D
Rationale: Assessing fundal tone and lochia flow is crucial in the early detection and prevention of postpartum hemorrhage. Fundal tone helps identify uterine atony, a common cause of postpartum hemorrhage, while monitoring lochia flow can indicate excessive bleeding. Cold packs on the perineum, although helpful for pain and swelling, are not the priority in this situation. Pain assessment and observing interactions with infants are important but secondary to assessing for signs of postpartum hemorrhage.
4. 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.
5. In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement?
- A. Document the extent of the bruising in the medical record.
- B. Apply a cold compress to the area.
- C. Elevate the affected limb.
- D. Notify the healthcare provider.
Correct answer: A
Rationale: After observing ecchymosis at the fracture site, indicating hematoma formation, the nurse's priority is to document the extent of the bruising in the medical record. This documentation helps track the client's condition, aids in treatment planning, and serves as a baseline for monitoring changes. Applying a cold compress (choice B) may be contraindicated due to the risk of vasoconstriction and potential tissue damage. Elevating the affected limb (choice C) can be beneficial for reducing swelling in some cases, but documenting the bruising is the immediate concern. Notifying the healthcare provider (choice D) is not necessary at this stage unless there are other concerning symptoms or complications beyond the hematoma formation.
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