HESI RN
HESI RN Exit Exam 2024 Quizlet
1. A client who is at 36 weeks gestation is admitted with severe preeclampsia. After a 6-gram loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate intervention by the nurse?
- A. Urine output of 20 ml/hour
- B. Blood pressure of 138/88
- C. Respiratory rate of 18 breaths/min
- D. Temperature of 99.8°F
Correct answer: A
Rationale: A urine output of less than 30 ml/hour indicates that the kidneys are being affected by the high level of magnesium sulfate. This decreased urine output can lead to magnesium toxicity and impaired kidney function. Blood pressure of 138/88 is within normal limits for pregnancy and does not indicate an immediate concern related to magnesium sulfate. A respiratory rate of 18 breaths/min is normal, and a temperature of 99.8°F is slightly elevated but not a priority in the context of severe preeclampsia and magnesium sulfate administration.
2. 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.
3. During the initial visit to a client with MS who is bed-bound and lifted by a hoist, which intervention is most important for the nurse to implement?
- A. Determine how the client is cared for when the caregiver is not present.
- B. Develop a client needs assessment and review it with the caregiver.
- C. Evaluate the caregiver's ability to care for the client's needs.
- D. Review with the caregiver the interventions provided each day.
Correct answer: A
Rationale: During the initial visit, the most crucial intervention for the nurse is to determine how the client is cared for when the caregiver is not present. This is essential to ensure the client's safety and well-being, especially during times when the caregiver is not available. Option B is not the most important as it focuses on assessment rather than immediate safety concerns. Option C, while important, is secondary to ensuring continuous care. Option D is less critical during the initial visit compared to ensuring care continuity in the caregiver's absence.
4. A client with cirrhosis is admitted with jaundice and ascites. Which intervention should the nurse implement first?
- A. Administer a diuretic as prescribed.
- B. Administer lactulose as prescribed.
- C. Monitor the client's weight daily.
- D. Assess the client's neurological status.
Correct answer: B
Rationale: Administering lactulose is the first priority in managing a client with cirrhosis to reduce ammonia levels and prevent worsening hepatic encephalopathy. Lactulose helps in decreasing the absorption of ammonia in the intestines and promotes its excretion through the stool. This intervention is crucial in preventing the development or progression of hepatic encephalopathy. Administering a diuretic (Choice A) may be necessary to manage ascites, but it is not the priority over lactulose in this scenario. Monitoring the client's weight (Choice C) is important to assess fluid retention but is not the first intervention required. Assessing the client's neurological status (Choice D) is essential in cirrhosis, but administering lactulose takes precedence to prevent hepatic encephalopathy.
5. A client is being treated with an aminoglycoside antibiotic for a serious gram-negative infection. What nursing action should be included in the plan of care to prevent nephrotoxicity?
- A. Monitor serum creatinine levels daily.
- B. Administer the antibiotic over a longer period of time.
- C. Encourage increased fluid intake.
- D. Restrict dietary protein intake.
Correct answer: A
Rationale: Monitoring serum creatinine levels daily is the essential nursing action to prevent nephrotoxicity from aminoglycoside antibiotics. Aminoglycosides can cause kidney damage, so monitoring serum creatinine levels helps in detecting early signs of nephrotoxicity. Administering the antibiotic over a longer period of time (choice B) does not directly prevent nephrotoxicity. Encouraging increased fluid intake (choice C) is a general good practice but not specifically aimed at preventing nephrotoxicity. Restricting dietary protein intake (choice D) is not a direct preventive measure against aminoglycoside-induced nephrotoxicity.
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