HESI RN
HESI Maternity 55 Questions Quizlet
1. A child who received multiple blood transfusions after correction of a congenital heart defect is demonstrating muscular irritability and oozing blood from the surgical incision. Which serum value is most important for the nurse to obtain before reporting to the healthcare provider?
- A. CO2 combining power
- B. Calcium
- C. Sodium
- D. Chloride
Correct answer: B
Rationale: The correct answer is Calcium. In this scenario, the child is displaying symptoms of muscular irritability and oozing blood, which are indicative of hypocalcemia. Calcium levels are crucial to monitor after multiple blood transfusions to prevent complications such as hypocalcemia, which can lead to these symptoms. Therefore, obtaining a serum calcium value is essential for the nurse to assess and address the child's condition effectively. CO2 combining power, Sodium, and Chloride levels are not directly associated with the symptoms described and are not the priority in this situation.
2. A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first?
- A. Transport the client to the seclusion room.
- B. Quietly approach the client with additional staff members.
- C. Take other clients in the area to the client lounge.
- D. Administer medication to chemically restrain the client.
Correct answer: B
Rationale: In situations where a client is agitated and refusing medication, a non-confrontational approach with additional staff can help de-escalate the situation and address the client's behavior safely. Transporting the client to the seclusion room (Choice A) should not be the initial intervention unless the client poses an immediate risk of harm to themselves or others. Taking other clients to the client lounge (Choice C) does not directly address the agitated client's behavior. Administering medication to chemically restrain the client (Choice D) should only be considered after other de-escalation attempts have been made and if there is a significant safety concern.
3. A client with functional urinary incontinence is being taught by a nurse. Which statement should the nurse include in this client’s teaching?
- A. Clean around your catheter daily with soap and water.
- B. Wash the vaginal weights with a 10% bleach solution after each use.
- C. Informing about available operations to repair your bladder.
- D. Buy slacks with elastic waistbands that are easy to pull down.
Correct answer: D
Rationale: Functional urinary incontinence is not related to bladder issues but rather to difficulties with ambulation or accessing the toilet. The goal is to help the client manage clothing independently. Elastic waistband slacks that are easy to pull down facilitate timely access to the toilet. Choices A and B are unrelated and not applicable to functional urinary incontinence. Choice C is incorrect as surgeries to repair the bladder are not indicated for functional urinary incontinence.
4. The nurse is caring for a client with deep vein thrombosis (DVT) who is receiving anticoagulant therapy. Which intervention should the nurse implement to prevent complications?
- A. Elevate the affected leg
- B. Encourage early ambulation
- C. Perform frequent range-of-motion exercises
- D. Apply ice packs to the affected leg
Correct answer: A
Rationale: Elevating the affected leg is crucial in managing deep vein thrombosis (DVT) as it helps to reduce swelling and improve venous return. This intervention is essential for preventing complications such as pulmonary embolism. Encouraging early ambulation is generally beneficial for preventing DVT but is secondary to leg elevation. Performing range-of-motion exercises can be helpful for maintaining joint mobility but is not the priority intervention in this case. Applying ice packs to the affected leg is not recommended in DVT management as it can cause vasoconstriction and potentially worsen the condition.
5. A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which laboratory value is most concerning?
- A. Serum glucose of 300 mg/dL
- B. Blood pressure of 140/90 mmHg
- C. Serum osmolarity of 320 mOsm/kg
- D. Serum pH of 7.30
Correct answer: C
Rationale: In a client with hyperglycemic hyperosmolar syndrome (HHS), a serum osmolarity of 320 mOsm/kg is the most concerning laboratory value. This high osmolarity indicates severe dehydration, which can lead to serious complications. Elevated serum glucose levels (choice A) are expected in HHS but do not directly reflect dehydration. Blood pressure (choice B) and serum pH (choice D) are important parameters to monitor but are not the most concerning values in HHS compared to serum osmolarity.