HESI RN
HESI 799 RN Exit Exam Quizlet
1. A male client with hypertension, who received new antihypertensive prescriptions at his last visit, returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106, and he admits that he has not been taking the prescribed medication because the drugs make him 'feel bad'. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?
- A. Blindness due to cataracts
- B. Acute kidney injury due to glomerular damage
- C. Stroke secondary to hemorrhage
- D. Heart block due to myocardial damage
Correct answer: C
Rationale: The correct answer is C, 'Stroke secondary to hemorrhage.' Uncontrolled hypertension can lead to the weakening of blood vessels in the brain, increasing the risk of a stroke due to hemorrhage. This can result in serious neurological deficits or even death. Choices A, B, and D are incorrect because while hypertension can have various complications including vision changes, kidney damage, and heart problems, the most immediate and severe risk associated with uncontrolled hypertension is a stroke from cerebral hemorrhage.
2. The nurse is administering an IV medication to a client with a history of anaphylaxis. Which intervention is most important for the nurse to implement?
- A. Stay with the client throughout the infusion.
- B. Keep emergency resuscitation equipment at the bedside.
- C. Obtain the client's allergy history.
- D. Ask the client about past allergic reactions to medications.
Correct answer: B
Rationale: Keeping emergency resuscitation equipment at the bedside is crucial in case the client experiences anaphylaxis during the infusion. While staying with the client throughout the infusion (Choice A) is important, having immediate access to emergency equipment takes priority in this situation. Obtaining the client's allergy history (Choice C) and asking about past allergic reactions to medications (Choice D) are relevant but do not address the immediate need for emergency intervention in case of anaphylaxis.
3. A client with a history of chronic kidney disease (CKD) is admitted with hyperkalemia. Which assessment finding requires immediate intervention?
- A. Peaked T waves on the ECG
- B. Bradycardia
- C. Decreased deep tendon reflexes
- D. Muscle weakness
Correct answer: A
Rationale: Peaked T waves on the ECG are a critical finding in hyperkalemia as they indicate potential life-threatening cardiac arrhythmias. Immediate intervention is necessary to prevent cardiac complications such as ventricular tachycardia or fibrillation. Bradycardia, decreased deep tendon reflexes, and muscle weakness are not typically associated with hyperkalemia and do not pose the same level of immediate risk to the client's life.
4. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first?
- A. Cleanse the foot with soap and water and apply an antibiotic ointment
- B. Provide teaching about the need for a tetanus booster within the next 72 hours.
- C. Have the mother check the child's temperature every 4 hours for the next 24 hours
- D. Transfer the child to the emergency department to receive a gamma globulin injection
Correct answer: A
Rationale: The correct first action for the nurse to implement is to cleanse the foot with soap and water and apply an antibiotic ointment to prevent infection. In cases of puncture wounds like stepping on a rusty nail, the immediate concern is to reduce the risk of infection. Providing teaching about the need for a tetanus booster within the next 72 hours is important as well, but it should come after the wound is cleansed. Checking the child's temperature and transferring to the emergency department for a gamma globulin injection are not the immediate priorities in this scenario.
5. 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.
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