HESI RN
HESI RN CAT Exit Exam 1
1. A client with chronic renal failure is receiving peritoneal dialysis. The nurse notes that the client's dialysate output is less than the input and that the client's abdomen is distended. What action should the nurse take first?
- A. Turn the client from side to side
- B. Increase the dwell time of the dialysis
- C. Reposition the client
- D. Milk the catheter
Correct answer: A
Rationale: The correct first action for the nurse to take is turning the client from side to side. This helps to facilitate drainage in peritoneal dialysis. Turning the client can aid in redistributing the dialysate and promoting better drainage. Increasing the dwell time of the dialysis (choice B) may not address the immediate issue of inadequate drainage. Repositioning the client (choice C) might not be as effective as turning the client from side to side. Milking the catheter (choice D) is not recommended as it can lead to complications. In this situation, the priority is to facilitate drainage to address the distended abdomen.
2. A client admitted to the hospital for depression is escorted to a private room. Prior to leaving the room, what intervention is most important for the nurse to implement?
- A. Explain the program's guidelines
- B. Search all personal belongings
- C. Initiate psychosocial assessment
- D. Review the healthcare provider's prescription
Correct answer: B
Rationale: Searching personal belongings is essential to ensure the safety of the client by preventing access to items that could be used for self-harm. While explaining the program's guidelines (Choice A) and initiating a psychosocial assessment (Choice C) are important aspects of care, the immediate concern in this situation is the safety of the client. Reviewing the healthcare provider's prescription (Choice D) is important for providing appropriate treatment but is not as urgent as ensuring the client's safety.
3. Which assessment finding should indicate to the nurse that a client with arterial hypertension is experiencing a cardiac complication?
- A. Complaints of an occipital headache
- B. A palpable dorsal pedis pulse bilaterally
- C. Complaints of shortness of breath on exertion
- D. A blood pressure of 160/90
Correct answer: C
Rationale: The correct answer is C, complaints of shortness of breath on exertion. This symptom is indicative of heart failure, a common cardiac complication of arterial hypertension. Shortness of breath on exertion is often due to the heart's inability to pump effectively, leading to fluid buildup in the lungs. Choices A, B, and D are incorrect because complaints of an occipital headache, a palpable dorsal pedis pulse bilaterally, and a blood pressure of 160/90 do not specifically indicate a cardiac complication in a client with arterial hypertension.
4. A nurse is assessing the learning needs of a client who is diagnosed with Addison's disease. Which statement indicates that the client needs further teaching?
- A. I should take my medications daily to replace necessary hormones
- B. I need to eat a diet high in protein and carbohydrates
- C. I should avoid drinking fluids with caffeine
- D. I should notify my healthcare provider if I start feeling dizzy
Correct answer: B
Rationale: The correct answer is B. A diet high in protein and carbohydrates is not specifically required for Addison's disease. The focus should be on maintaining a balanced diet that is rich in fruits, vegetables, whole grains, and adequate protein sources. Choice A is correct as adherence to medication therapy is crucial in managing Addison's disease. Choice C is correct as caffeine can exacerbate symptoms of Addison's disease. Choice D is correct as dizziness can be a sign of adrenal crisis in Addison's disease, and prompt notification of healthcare providers is essential.
5. The nurse is planning care for a client who is receiving radiation therapy for breast cancer. Which intervention is most important for the nurse to include?
- A. Encourage the client to use sunscreen
- B. Apply lotion to the radiated area
- C. Keep the area dry and clean
- D. Encourage the client to exercise the arm
Correct answer: C
Rationale: Keeping the radiated area dry and clean is crucial to prevent skin irritation and infection. Radiation therapy can cause skin changes, making it susceptible to irritation and infection. Using sunscreen (Choice A) is not usually recommended on the radiated area as it can further irritate the skin. Applying lotion (Choice B) may not be suitable as it can trap moisture and cause skin breakdown. While encouraging exercise (Choice D) is important, keeping the area dry and clean takes precedence to prevent complications during radiation therapy.
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