HESI RN TEST BANK

HESI RN CAT Exit Exam 1

A client who had an intraosseous (IO) cannula placed by the healthcare provider for emergent fluid resuscitation is complaining of severe pain and numbness below the IO site. The skin around the site is pale and edematous. What action should the nurse take first?

    A. Discontinue the IO infusion

    B. Administer an analgesic via the IO site

    C. Elevate the extremity with the IO site

    D. Notify the healthcare provider

Correct Answer: A
Rationale: In this scenario, the client's symptoms of severe pain, numbness, pale skin, and edema below the IO site raise concerns for complications like compartment syndrome or extravasation. The priority action for the nurse is to discontinue the IO infusion to prevent further harm to the client. Administering an analgesic via the IO site or elevating the extremity with the IO site may delay addressing the potential serious complications. While notifying the healthcare provider is important, the immediate action to ensure client safety is to stop the infusion.

A client receiving amlodipine (Norvasc), a calcium channel blocker, develops 1+ pitting edema around the ankles. It is most important for the nurse to obtain what additional client data?

  • A. Bladder distention
  • B. Serum albumin level
  • C. Abdominal girth
  • D. Breath sounds

Correct Answer: D
Rationale: The correct answer is 'D. Breath sounds.' When a client receiving amlodipine develops edema, it is crucial to assess for potential heart failure, a side effect of the medication. Checking breath sounds helps in identifying any signs of pulmonary edema, a severe complication of heart failure. Choices A, B, and C are less relevant in this context. Bladder distention could be associated with urinary issues, serum albumin level with malnutrition or liver disease, and abdominal girth with gastrointestinal problems, none of which directly relate to the potential heart failure induced by amlodipine.

A healthcare provider is assessing a client who is receiving treatment for dehydration. Which assessment finding indicates that the client is responding to the treatment?

  • A. Dry mucous membranes
  • B. Increased urine output
  • C. Decreased skin turgor
  • D. Elevated heart rate

Correct Answer: B
Rationale: Increased urine output is a positive sign indicating that the client is responding to the treatment for dehydration. It suggests that the client's kidneys are functioning better, helping to eliminate excess fluid and waste products from the body. Dry mucous membranes (Choice A) are a sign of dehydration, not improvement. Decreased skin turgor (Choice C) and elevated heart rate (Choice D) are also symptoms of dehydration and do not indicate a positive response to treatment.

The nurse is planning a health fair for young adults. Which action is most important for the nurse to implement?

  • A. Provide educational materials on smoking cessation
  • B. Offer blood pressure screening and monitoring
  • C. Provide information on safe sex practices
  • D. Discuss the importance of a healthy diet and exercise

Correct Answer: B
Rationale: Offering blood pressure screening and monitoring is crucial for young adults as it helps in the early detection and management of hypertension, a condition that often goes unnoticed. High blood pressure can lead to serious health issues if left untreated. While education on smoking cessation, safe sex practices, healthy diet, and exercise are important aspects of overall health promotion, blood pressure screening takes precedence due to its immediate impact on health and the prevention of potential complications.

The nurse is caring for a client who is receiving a continuous intravenous infusion of heparin. Which laboratory value should the nurse monitor to evaluate the effectiveness of the therapy?

  • A. Platelet count
  • B. Prothrombin time (PT)
  • C. Partial thromboplastin time (PTT)
  • D. Hemoglobin level

Correct Answer: C
Rationale: The correct answer is C. Partial thromboplastin time (PTT) is the laboratory value that should be monitored to evaluate the effectiveness of heparin therapy. PTT reflects the intrinsic pathway of coagulation and is specifically sensitive to heparin's anticoagulant effects. Monitoring the PTT helps ensure that the client is within the therapeutic range to prevent clot formation without increasing the risk of bleeding. Choices A, B, and D are incorrect because while they are important laboratory values in other contexts, they are not specifically used to monitor the effectiveness of heparin therapy.

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