HESI RN
HESI RN Exit Exam 2024 Quizlet
1. The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which clinical finding requires immediate intervention?
- A. Increased fatigue
- B. Elevated blood pressure
- C. Headache
- D. Elevated hemoglobin
Correct answer: A
Rationale: The correct answer is A, 'Increased fatigue.' In a client with CKD receiving erythropoietin therapy, increased fatigue can be a sign of polycythemia, a condition characterized by an elevated red blood cell count. This can lead to increased blood viscosity and raise the risk of thromboembolic events, necessitating immediate intervention. Elevated blood pressure (choice B) is a common concern in CKD but does not require immediate intervention in this context. Headache (choice C) may be related to elevated blood pressure but is not the most critical finding requiring immediate attention. Elevated hemoglobin (choice D) is an expected outcome of erythropoietin therapy and does not require immediate intervention unless excessively high.
2. A client with rheumatoid arthritis is prescribed methotrexate. Which laboratory value should the nurse monitor closely?
- A. White blood cell count of 10,000/mm³
- B. Hemoglobin of 12 g/dL
- C. Liver function tests
- D. Platelet count of 150,000/mm³
Correct answer: C
Rationale: The correct answer is C: Liver function tests. Methotrexate can cause hepatotoxicity, making it essential to closely monitor liver function tests in clients receiving this medication. Monitoring white blood cell count, hemoglobin, or platelet count is not specifically required for methotrexate therapy and would not provide relevant information regarding potential adverse effects of the medication.
3. The nurse is caring for a client with diabetic ketoacidosis (DKA). Which intervention is most important?
- A. Administer insulin as prescribed.
- B. Monitor the client's urine output.
- C. Assess the client's level of consciousness.
- D. Obtain an arterial blood gas (ABG) sample.
Correct answer: A
Rationale: Administering insulin is the most crucial intervention in managing diabetic ketoacidosis. Insulin helps reduce blood glucose levels and correct metabolic acidosis, which are the primary issues in DKA. Monitoring urine output (Choice B) is important but not as critical as administering insulin. Assessing the client's level of consciousness (Choice C) is essential but does not directly address the underlying cause of DKA. Obtaining an arterial blood gas sample (Choice D) can provide valuable information but is not as urgent as administering insulin to address the immediate metabolic imbalance.
4. A client with cirrhosis is admitted with jaundice and ascites. Which clinical finding is most concerning?
- A. Increased abdominal girth
- B. Confusion and altered mental status
- C. Yellowing of the skin
- D. Peripheral edema
Correct answer: B
Rationale: Confusion and altered mental status are concerning in a client with cirrhosis as they may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Increased abdominal girth can be seen in ascites, yellowing of the skin is due to jaundice, and peripheral edema is associated with fluid retention in cirrhosis, but confusion and altered mental status are more closely linked to hepatic encephalopathy, which can progress rapidly and needs urgent attention.
5. A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a 'Do Not Resuscitate' prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. What action should the nurse take?
- A. Advise the UAP to resume positioning the client on schedule
- B. Notify the healthcare provider
- C. Document the UAP's actions
- D. Discuss the situation with the client’s family
Correct answer: A
Rationale: Continuing to turn the client is crucial to prevent complications such as pressure ulcers, even if the client is less responsive. Advising the UAP to resume positioning the client on schedule is the most appropriate action in this situation. This action ensures that the client's care needs are met and helps prevent potential complications. Notifying the healthcare provider or documenting the UAP's actions may delay the necessary care for the client. Discussing the situation with the client's family is important but addressing the immediate care need of turning the client takes priority.
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