a client is receiving a full strength continuous enteral tube feeding at 50 mlhour and has developed diarrhea the client has a new prescription to cha
Logo

Nursing Elites

HESI RN

RN HESI Exit Exam

1. A client is receiving a full-strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement?

Correct answer: A

Rationale: The correct intervention is to dilute the formula by adding equal amounts of water and feeding to a feeding bag and infusing it at 50 ml/hour. This can help alleviate the diarrhea that has developed. Diarrhea can occur as a complication of enteral tube feeding and can be due to a variety of causes, including hyperosmolar formula. Choice B is incorrect as continuing the full-strength feeding, even at a lower rate, may not address the issue of diarrhea. Choice C is incorrect because it is important to follow the new prescription to manage the diarrhea effectively. Choice D is incorrect as withholding feeding without taking appropriate action may delay necessary intervention.

2. The nurse is caring for a client with chronic kidney disease (CKD). Which laboratory value should be reported to the healthcare provider immediately?

Correct answer: C

Rationale: The correct answer is C. A potassium level of 6.5 mEq/L is dangerously high, a condition known as hyperkalemia, and requires immediate intervention to prevent cardiac complications. Hyperkalemia can lead to life-threatening arrhythmias, making it crucial to notify the healthcare provider promptly. Choices A, B, and D do not indicate immediate life-threatening conditions. Elevated serum creatinine levels are expected in CKD, a hemoglobin level of 10 g/dl is within a reasonable range, and a blood glucose level of 150 mg/dl is not acutely concerning in this context.

3. A 66-year-old woman is retiring and will no longer have health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs?

Correct answer: C

Rationale: The correct answer is C: Medicare. Title XVII of the Social Security Act of 1965 created the Medicare Program to provide medical insurance for individuals who are 65 years or older, disabled, or have permanent kidney failure. Medicare is the appropriate agency to refer a 66-year-old woman who is retiring and losing her employment-based health insurance. Choice A, the Woman, Infants, and Children program, is not suitable for this scenario as it provides assistance for low-income pregnant women, breastfeeding women, and young children. Choice B, Medicaid, is a program that helps individuals with low income and resources cover medical costs, which may not be applicable to this woman's situation. Choice D, the Consolidated Omnibus Budget Reconciliation Act provision, known as COBRA, allows employees to continue their group health insurance coverage after leaving their job but may not be the best option for this woman in this case.

4. A client with a history of chronic kidney disease (CKD) is admitted with hyperkalemia. Which assessment finding requires immediate intervention?

Correct answer: A

Rationale: Peaked T waves on the ECG are a critical finding in hyperkalemia as they indicate potential life-threatening cardiac arrhythmias. Immediate intervention is necessary to prevent cardiac complications such as ventricular tachycardia or fibrillation. Bradycardia, decreased deep tendon reflexes, and muscle weakness are not typically associated with hyperkalemia and do not pose the same level of immediate risk to the client's life.

5. A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever. Which instructions should the nurse give to this client?

Correct answer: A

Rationale: The correct answer is to advise the client to come to the clinic to be seen by a healthcare provider. Persistent vomiting during pregnancy can lead to dehydration, which requires medical evaluation. Choice B is incorrect because solely increasing fluid intake and resting at home may not be sufficient to address the potential dehydration and underlying causes of vomiting. Choice C is not recommended without medical evaluation, as over-the-counter antiemetics should be used under healthcare provider guidance during pregnancy. Choice D is not the best option here because with persistent vomiting and risk of dehydration, immediate medical assessment is crucial to ensure the well-being of both the client and the fetus.

Similar Questions

The client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which laboratory value is most concerning?
A nurse is preparing to administer a dose of digoxin (Lanoxin) to a client with heart failure. Which assessment finding requires immediate intervention?
The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should the nurse monitor closely?
A client with chronic obstructive pulmonary disease (COPD) is experiencing shortness of breath and has a prescription for oxygen therapy. What is the maximum amount of oxygen the nurse should administer without a healthcare provider's order?
A client who has just returned from surgery is shivering uncontrollably. What is the best action for the nurse to take?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses