HESI RN
HESI RN Exit Exam 2024 Quizlet Capstone
1. An older client with type 1 diabetes arrives at the clinic with abdominal cramping, vomiting, lethargy, and confusion. What should the nurse implement first?
- A. Start an IV infusion of normal saline.
- B. Obtain a serum potassium level.
- C. Administer the client's usual dose of insulin.
- D. Assess the pupillary response to light.
Correct answer: A
Rationale: The correct answer is A: Start an IV infusion of normal saline. The client is showing signs of dehydration, such as abdominal cramping, vomiting, lethargy, and confusion, which can be exacerbated by hyperglycemia. Rehydration is the initial priority to address the fluid imbalance. Option B, obtaining a serum potassium level, though important in the management of diabetes, is not the immediate priority over rehydration. Option C, administering the client's usual dose of insulin, should only be done after addressing the dehydration and confirming the client's blood glucose levels. Option D, assessing the pupillary response to light, is not the most urgent intervention needed in this situation compared to rehydration to correct fluid imbalance.
2. A client with emphysema reports shortness of breath. What is the nurse's priority action?
- A. Administer oxygen therapy.
- B. Assess the client’s respiratory rate and effort.
- C. Prepare the client for intubation.
- D. Increase the client's oxygen flow rate.
Correct answer: B
Rationale: Shortness of breath in a client with emphysema may indicate respiratory distress. Assessing the client’s respiratory rate and effort is the first priority to determine the severity of the distress and guide appropriate interventions. Administering oxygen therapy (Choice A) could be necessary, but assessing the client first is crucial to tailor the intervention. Intubation (Choice C) is an invasive procedure that is not the initial priority. Increasing oxygen flow rate (Choice D) should only be done after a thorough assessment to avoid potential harm.
3. A client with heart failure is prescribed digoxin and reports nausea. What is the nurse's first action?
- A. Administer an anti-nausea medication as prescribed.
- B. Assess the client's digoxin level immediately.
- C. Assess the client’s apical pulse and hold the next dose if it's below 60 bpm.
- D. Instruct the client to reduce their fluid intake.
Correct answer: B
Rationale: When a client on digoxin reports nausea, it can be a sign of digoxin toxicity. The priority action for the nurse is to assess the client's digoxin level immediately. This assessment will help determine if the nausea is related to digoxin toxicity, requiring a dosage adjustment. Administering an anti-nausea medication (Choice A) does not address the underlying issue of potential digoxin toxicity. Assessing the client's apical pulse (Choice C) is important in general digoxin monitoring but not the first action when nausea is reported. Instructing the client to reduce fluid intake (Choice D) is not the initial response to nausea in a client taking digoxin.
4. While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?
- A. White blood cell count
- B. Hemoglobin
- C. Serum creatinine
- D. Culture for sensitive organisms
Correct answer: D
Rationale: Purulent drainage suggests an infection at the wound site. Reviewing the culture and sensitivity results will guide appropriate antibiotic treatment by identifying the causative organisms and their antibiotic sensitivities. Elevated white blood cells indicate infection but do not specify the organism. Creatinine and hemoglobin values are unrelated to wound infections.
5. A client with cirrhosis and ascites asks about fluid restriction. What is the nurse’s best response?
- A. Increase the client's fluid intake gradually.
- B. Restrict oral fluids to 1500 ml per day.
- C. Explain the importance of following a low-sodium diet.
- D. Increase dietary protein to reduce fluid retention.
Correct answer: B
Rationale: The correct answer is B: 'Restrict oral fluids to 1500 ml per day.' In clients with cirrhosis and ascites, fluid restriction is essential to prevent fluid overload, which can worsen symptoms of liver failure. Option A is incorrect because increasing fluid intake would exacerbate the issue of fluid overload. Option C, while important, is not the best initial response to the client's question about fluid restriction. Option D is incorrect as increasing dietary protein does not directly address fluid restriction in clients with cirrhosis and ascites.
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