HESI RN
HESI RN CAT Exam Quizlet
1. A client who is 32-weeks pregnant is diagnosed with partial placenta previa. Which instruction should the nurse include in this client’s teaching plan?
- A. Wear a tight abdominal binder at all times
- B. Take a daily laxative to prevent constipation
- C. Refrain from sexual intercourse until your next appointment
- D. Restrict fluids to less than 1000 ml per day
Correct answer: C
Rationale: Refraining from sexual intercourse helps prevent complications with partial placenta previa.
2. The nurse is caring for a client following a craniotomy. Which finding should the nurse report immediately?
- A. Pupils equal and reactive to light.
- B. Sudden increase in urine output.
- C. Diminished breath sounds bilaterally.
- D. Increase in blood pressure by 20 mmHg.
Correct answer: C
Rationale: The correct answer is C, 'Diminished breath sounds bilaterally.' This finding should be reported immediately as it could indicate a serious complication such as increased intracranial pressure or respiratory compromise. In a post-craniotomy client, changes in breath sounds may be a sign of developing issues that need prompt intervention. Choices A, B, and D are not as critical in the immediate post-craniotomy period. Pupils equal and reactive to light are expected findings, a sudden increase in urine output may require monitoring but not immediate reporting, and a small increase in blood pressure may not be alarming unless it is significantly high or accompanied by other concerning signs.
3. A client with chronic kidney disease (CKD) is receiving erythropoietin therapy. Which laboratory value should the nurse monitor closely?
- A. Serum potassium
- B. Hemoglobin
- C. White blood cell count
- D. Serum creatinine
Correct answer: A
Rationale: The correct answer is A: Serum potassium. When a client with chronic kidney disease is receiving erythropoietin therapy, monitoring serum potassium closely is essential. Erythropoietin therapy can lead to increased red blood cell production, which may cause potassium levels to rise, potentially resulting in hyperkalemia. Monitoring potassium levels helps prevent complications associated with hyperkalemia. Choices B, C, and D are incorrect because they are not directly impacted by erythropoietin therapy in the context of CKD.
4. An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The nurse notices the client has more energy and is giving her belongings away. Which intervention is best for the nurse to implement?
- A. Support the client by praising her progress.
- B. Ask the client if she has had any recent thoughts of harming herself.
- C. Reassure the client about the effectiveness of antidepressant drugs.
- D. Advise the client to keep her belongings for discharge.
Correct answer: B
Rationale: The correct intervention is to ask the client if she has had any recent thoughts of harming herself because increased energy and giving away belongings can be signs of suicidal ideation. Choice A is incorrect as it does not address the potential risk of self-harm. Choice C is incorrect because reassurance about medication effectiveness may not be appropriate in this situation. Choice D is incorrect as it dismisses the client's current behavior without addressing the underlying concern of potential self-harm.
5. A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the nurse to ask the client?
- A. Have you lost interest in activities you used to enjoy?
- B. Has your ability to think or concentrate decreased?
- C. How many consecutive hours do you sleep at night?
- D. Do you hear sounds or voices that others do not hear?
Correct answer: D
Rationale: Inquiring about hallucinations is crucial for assessing the return of psychotic symptoms due to discontinuation of antipsychotic medication. Hearing sounds or voices that others do not hear can indicate the presence of auditory hallucinations, a common symptom in schizophrenia. Choices A, B, and C are important aspects to assess in clients with schizophrenia, but in this scenario, the priority is to determine if the client is experiencing hallucinations, which can be a sign of worsening psychotic symptoms.