HESI RN
HESI RN Exit Exam 2024 Quizlet Capstone
1. A client receiving lactulose for hepatic encephalopathy needs evaluation. Which assessment should the nurse prioritize?
- A. Percussion of the abdomen.
- B. Blood glucose level.
- C. Serum electrolytes.
- D. Level of consciousness.
Correct answer: D
Rationale: The correct answer is D: Level of consciousness. When managing hepatic encephalopathy with lactulose, monitoring the client's level of consciousness is crucial as it is a key indicator of the therapeutic response to lactulose in reducing ammonia levels. Changes in consciousness can reflect the effectiveness of treatment and the progression of hepatic encephalopathy. Option A, percussion of the abdomen, is not directly related to evaluating the response to lactulose. Option B, blood glucose level, is important but not the priority in this context. Option C, serum electrolytes, while significant in liver disease, do not directly assess the impact of lactulose therapy on hepatic encephalopathy.
2. The nurse is providing discharge instructions to a client after a total hip replacement. Which statement by the client indicates a need for further teaching?
- A. I will avoid crossing my legs when sitting.
- B. I will use a raised toilet seat to prevent bending too far.
- C. I should keep my legs together to prevent dislocation.
- D. I will use a walker when moving around initially.
Correct answer: C
Rationale: The correct answer is C. Clients who have had a hip replacement should not keep their legs together to prevent dislocation. This position increases the risk of hip dislocation. Choices A, B, and D are correct statements. Avoiding crossing legs, using a raised toilet seat to prevent excessive bending, and using a walker when moving around initially are all appropriate measures to ensure proper recovery and prevent complications after a total hip replacement.
3. A client on mechanical ventilation is experiencing high-pressure alarms. What action should the nurse implement first?
- A. Check the client's oxygen saturation.
- B. Assess the client's endotracheal tube for obstruction.
- C. Reposition the client to relieve pressure.
- D. Suction the client's airway.
Correct answer: B
Rationale: The correct answer is to assess the client's endotracheal tube for obstruction. When a client on mechanical ventilation experiences high-pressure alarms, the first action should be to check for any potential obstructions in the airway, which can trigger the alarms. Checking the oxygen saturation (Choice A) is important but not the priority when dealing with high-pressure alarms. Repositioning the client (Choice C) may be necessary later but should not be the initial action. Suctioning the client's airway (Choice D) should only be done after assessing for and addressing any obstructions in the endotracheal tube.
4. A client with deep vein thrombosis (DVT) is receiving heparin and reports tarry stools. What should the nurse do?
- A. Prepare to administer warfarin.
- B. Assess characteristics of the client's pain.
- C. Monitor stools for blood and review PTT results.
- D. Continue the heparin and prepare to administer Vitamin K.
Correct answer: C
Rationale: When a client on heparin reports tarry stools, it can be indicative of gastrointestinal bleeding. The correct action for the nurse is to monitor the stools for blood and review the Partial Thromboplastin Time (PTT) results. This is essential to detect any potential bleeding complications associated with heparin therapy. Option A is incorrect because warfarin is not the immediate intervention for tarry stools in a client on heparin. Option B is irrelevant to the situation described. Option D is incorrect as Vitamin K is the antidote for warfarin, not heparin.
5. A client with chronic obstructive pulmonary disease (COPD) is experiencing increased shortness of breath and fatigue. What is the nurse's first action?
- A. Administer a bronchodilator as prescribed.
- B. Check the client's oxygen saturation.
- C. Reposition the client to a high Fowler's position.
- D. Administer oxygen via nasal cannula.
Correct answer: B
Rationale: The correct first action for a client with COPD experiencing increased shortness of breath and fatigue is to check the client's oxygen saturation. This assessment helps the nurse evaluate the client's respiratory status promptly. Administering a bronchodilator (Choice A) may be necessary but should come after assessing the oxygen saturation. Repositioning the client to a high Fowler's position (Choice C) can help improve breathing but should not precede oxygen saturation assessment. Administering oxygen via nasal cannula (Choice D) may be needed based on the oxygen saturation results, but assessing it first is crucial.
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