HESI RN
HESI Fundamentals Quizlet
1. A client is to receive cimetidine (Tagamet) 300 mg q6h IVP. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion?
- A. 75 ml/hr
- B. 150 ml/hr
- C. 225 ml/hr
- D. 300 ml/hr
Correct answer: B
Rationale: To calculate the infusion rate, set up a ratio proportion problem: 50 ml/20 min = x ml/60 min. Cross multiply to solve: 50 × 60 / 20 = 150 ml/hr. Therefore, the infusion pump should be set to deliver the secondary infusion at a rate of 150 ml/hr. Option A, 75 ml/hr, is incorrect because it does not account for the correct calculation. Option C, 225 ml/hr, is incorrect as it is too high a rate based on the calculation. Option D, 300 ml/hr, is also incorrect as it does not align with the correct calculation for the infusion rate.
2. A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?
- A. Inform the client that the blood pressure is high and that the reading needs to be verified by another nurse.
- B. Contact the healthcare provider to report the reading and obtain a prescription for an antihypertensive medication.
- C. Replace the cuff with a larger one to ensure a proper fit for the client and increase arm comfort.
- D. Compare the current reading with the client's previously documented blood pressure readings.
Correct answer: D
Rationale: The correct action for the nurse to take first in this situation is to compare the current blood pressure reading with the client's previously documented readings. This comparison will provide valuable information about what is normal for this specific client, helping to determine if the current reading represents a significant change or if it falls within the client's usual range. By reviewing the client's past readings, the nurse can assess trends, variations, and if the current reading is an isolated high value or part of a pattern, guiding appropriate decision-making. Informing the client about the high reading (Choice A) or contacting the healthcare provider for medication (Choice B) should come after assessing the client's history. Replacing the cuff (Choice C) is not necessary at this point and does not address the immediate need to compare the readings for appropriate intervention.
3. The client has received a new diagnosis of heart failure, and the nurse is providing dietary management education. Which instruction should the nurse include?
- A. Increase intake of foods high in potassium.
- B. Avoid foods high in sodium.
- C. Limit fluid intake to 1.5 liters per day.
- D. Increase intake of foods high in vitamin K.
Correct answer: B
Rationale: Avoiding foods high in sodium (choice B) is essential for clients with heart failure to prevent fluid retention and decrease the strain on the heart. High sodium intake can lead to fluid buildup, exacerbating heart failure symptoms. Increasing potassium intake (choice A) can be harmful in heart failure if not monitored closely as it can affect heart rhythm. Limiting fluid intake (choice C) may be necessary in some cases, but the specific amount should be individualized based on the client's condition. Increasing vitamin K intake (choice D) is not a primary concern in heart failure management and is more relevant for clients on anticoagulants to manage blood clotting.
4. A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump?
- A. 13 ml/hour.
- B. 63 ml/hour.
- C. 80 ml/hour.
- D. 125 ml/hour.
Correct answer: B
Rationale: The correct calculation involves dividing the total volume by the total time. In this case, 250 ml/4 hours = 63 ml/hour. The dose of KCl is not used in the calculation as the focus is on the rate of infusion over the specified time period. Choice A (13 ml/hour) is incorrect as it does not result from the correct calculation. Choice C (80 ml/hour) and Choice D (125 ml/hour) are also incorrect calculations and do not match the correct rate of infusion required.
5. The healthcare provider is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?
- A. A college-age track runner with a sprained ankle.
- B. A lactating woman nursing her 3-day-old infant.
- C. A school-aged child with Type 2 diabetes.
- D. An elderly man being treated for a peptic ulcer.
Correct answer: B
Rationale: A lactating woman (B) has the greatest need for additional protein intake. Lactation increases the metabolic demands for protein to support milk production, making it essential for the mother to have a higher protein intake. While clients in choices A, C, and D also require protein for various reasons, they do not have the same increased protein demands as a lactating woman. Choice A, a college-age track runner with a sprained ankle, may need protein for tissue repair but not at the level required during lactation. Choice C, a school-aged child with Type 2 diabetes, may benefit from protein for overall health but does not have the same increased protein needs as a lactating woman. Choice D, an elderly man being treated for a peptic ulcer, may need protein for healing but not to the extent required by a lactating woman.
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