HESI RN
HESI 799 RN Exit Exam Quizlet
1. One day after abdominal surgery, an obese client complains of pain and heaviness in the right calf. What action should the nurse implement?
- A. Observe for unilateral swelling
- B. Administer pain medication
- C. Elevate the leg and apply a warm compress
- D. Notify the healthcare provider
Correct answer: A
Rationale: The correct action for the nurse to implement is to observe for unilateral swelling. Unilateral swelling could indicate a deep vein thrombosis (DVT), which is a serious complication that requires immediate assessment. Administering pain medication or applying warm compress may not address the underlying cause of the symptoms. Notifying the healthcare provider should be done after assessing and identifying the issue of unilateral swelling.
2. A client with a nasogastric tube in place following gastric surgery reports nausea. What is the most appropriate nursing action?
- A. Irrigate the NG tube with 30 ml of normal saline.
- B. Administer an antiemetic as prescribed.
- C. Assess the NG tube for patency and reposition if necessary.
- D. Provide sips of water and reassess the client's symptoms.
Correct answer: C
Rationale: Assessing the NG tube for patency and repositioning it if necessary is the most appropriate action to relieve the client's nausea. Nausea in a client with a nasogastric tube can be due to the tube's malposition or blockage. Irrigating the NG tube with normal saline (Choice A) without assessing for patency or repositioning may worsen the situation. Administering an antiemetic (Choice B) can help manage symptoms but does not address the potential issue with the NG tube. Providing sips of water and reassessing symptoms (Choice D) may be contraindicated if there is a problem with the NG tube and could exacerbate the nausea.
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 client with a history of rheumatoid arthritis is prescribed prednisone. Which assessment finding requires immediate intervention?
- A. Increased joint pain
- B. Weight gain of 2 pounds in 24 hours
- C. Blood glucose level of 150 mg/dl
- D. Fever of 100.4°F
Correct answer: B
Rationale: The correct answer is B. Weight gain of 2 pounds in 24 hours is concerning in a client with rheumatoid arthritis on prednisone as it may indicate fluid retention or worsening heart failure. Increased joint pain, blood glucose level of 150 mg/dl, and fever of 100.4°F are important assessments but do not require immediate intervention compared to the potential severity of rapid weight gain.
5. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which finding requires immediate intervention?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 24 breaths per minute
- C. Use of accessory muscles
- D. Blood pressure of 110/70 mmHg
Correct answer: C
Rationale: The correct answer is C. The use of accessory muscles indicates increased work of breathing and may signal respiratory failure in a client with COPD, requiring immediate intervention. Oxygen saturation of 90% is within an acceptable range for COPD patients on supplemental oxygen. A respiratory rate of 24 breaths per minute is slightly elevated but not an immediate concern. A blood pressure of 110/70 mmHg is within the normal range and does not require immediate intervention in this scenario.
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