HESI RN
HESI 799 RN Exit Exam Quizlet
1. The nurse is reinforcing home care instructions with a client who is being discharged following a transurethral resection of the prostate (TURP). Which intervention is most important for the nurse to include in the client teaching?
- A. Avoid strenuous activity for 6 weeks.
- B. Report fresh blood in the urine.
- C. Take acetaminophen for a fever over 101°F.
- D. Consume 6 to 8 glasses of water daily.
Correct answer: B
Rationale: Reporting fresh blood in the urine is crucial as it may indicate postoperative complications requiring immediate attention. This symptom can be a sign of bleeding, infection, or other issues that need prompt medical evaluation. Avoiding strenuous activity for 6 weeks is important but not as urgent as reporting fresh blood. Taking acetaminophen for a fever over 101°F is relevant but addressing fresh blood in the urine takes precedence. Consuming an adequate amount of water daily is beneficial but not as critical as recognizing and reporting signs of potential complications.
2. A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication?
- A. Increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure
- B. The antagonistic interaction among the various blood pressure medications has reduced their effectiveness
- C. The additive effect of multiple medications has caused the blood pressure to drop too low.
- D. The synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension.
Correct answer: C
Rationale: When medications with a similar action are administered, an additive effect occurs that is the sum of the effects of each medication. In this case, several medications that all lower blood pressure, when administered together, resulted in hypotension.
3. What is the first action the nurse should implement for a client admitted with acute pancreatitis?
- A. Administer intravenous fluids as prescribed
- B. Administer pain medication as prescribed
- C. Place the client on NPO status
- D. Assess the client's abdomen for distention
Correct answer: C
Rationale: Placing the client on NPO status is the priority action for a client with acute pancreatitis. This step is crucial to rest the pancreas, prevent pancreatic stimulation, and decrease enzyme production. By withholding oral intake, the digestive system is given a chance to rest and recover. Administering intravenous fluids may be necessary but should come after placing the client on NPO status. Pain medication can be administered once the client is stabilized. Assessing the client's abdomen for distention is important but is not the initial priority in managing acute pancreatitis.
4. When assessing a client with left-sided heart failure, which intervention should the nurse implement first?
- A. Administer oxygen therapy as prescribed.
- B. Monitor the client's urine output.
- C. Administer a loop diuretic as prescribed.
- D. Administer morphine as prescribed.
Correct answer: A
Rationale: Administering oxygen therapy is the initial intervention for a client with left-sided heart failure. This action is crucial in improving oxygen levels and reducing pulmonary congestion. Monitoring urine output is important for assessing renal function in heart failure, but it is not the priority over ensuring adequate oxygenation. Administering loop diuretics helps manage fluid overload but should come after addressing oxygen needs. Morphine may be indicated for pain or anxiety in some cases, but it is not the primary intervention for left-sided heart failure.
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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