HESI RN
HESI RN Exit Exam 2024 Quizlet
1. A client who is at 36 weeks gestation is admitted with severe preeclampsia. After a 6-gram loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate intervention by the nurse?
- A. Urine output of 20 ml/hour
- B. Blood pressure of 138/88
- C. Respiratory rate of 18 breaths/min
- D. Temperature of 99.8°F
Correct answer: A
Rationale: A urine output of less than 30 ml/hour indicates that the kidneys are being affected by the high level of magnesium sulfate. This decreased urine output can lead to magnesium toxicity and impaired kidney function. Blood pressure of 138/88 is within normal limits for pregnancy and does not indicate an immediate concern related to magnesium sulfate. A respiratory rate of 18 breaths/min is normal, and a temperature of 99.8°F is slightly elevated but not a priority in the context of severe preeclampsia and magnesium sulfate administration.
2. What action should be implemented when preparing to measure the fundal height of a pregnant client?
- A. Have the client empty her bladder.
- B. Request the client lie on her left side.
- C. Perform Leopold's maneuvers first.
- D. Give the client some cold juice to drink.
Correct answer: A
Rationale: The correct action when preparing to measure the fundal height of a pregnant client is to have the client empty her bladder. This is essential to ensure an accurate measurement because a full bladder can displace the uterus and affect the accuracy of the assessment. Choice B is incorrect because the client should lie flat on her back, not on her left side, to measure fundal height accurately. Choice C is incorrect because Leopold's maneuvers are used to determine the position of the fetus, not to measure fundal height. Choice D is incorrect as giving the client cold juice is not necessary for measuring fundal height.
3. A client admitted from a nursing home after several recent falls needs a urine sample for culture and sensitivity. What should the nurse complete first?
- A. Obtain urine sample for culture and sensitivity.
- B. Administer intravenous antibiotics.
- C. Encourage protein intake and additional fluids.
- D. Consult physical therapy for gait training.
Correct answer: A
Rationale: In this scenario, the priority intervention is to obtain a urine sample for culture and sensitivity. Older adults with recent falls may have atypical symptoms of urinary tract infection (UTI), which can present as new-onset confusion or falling. It is crucial to rule out UTI before initiating antibiotics. While administering antibiotics, encouraging protein intake, fluids, and consulting physical therapy are important interventions, they should follow the urine sample collection to ensure accurate diagnosis and appropriate treatment.
4. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?
- A. Sensory perceptual alterations related to decreased vision
- B. Alteration in mobility related to fatigue
- C. Impaired gas exchange related to retained secretions
- D. Altered patterns of urinary elimination related to nocturia
Correct answer: D
Rationale: The correct answer is D: Altered patterns of urinary elimination related to nocturia. Nocturia increases the risk of falls in elderly clients due to frequent nighttime trips to the bathroom. Choice A is incorrect because while decreased vision can contribute to falls, nocturia poses a more direct risk. Choice B is incorrect as fatigue may affect mobility but is not as directly linked to falls as nocturia. Choice C is incorrect as impaired gas exchange is not typically associated with an increased risk of falls.
5. The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get out of the room because her husband is too ill to get out of bed. What should the nurse do first?
- A. Administer nasal oxygen at a rate of 5 L/min
- B. Help the client to lie back down in the bed
- C. Quickly pivot the client to the chair and elevate the legs
- D. Check the client’s blood pressure and pulse
Correct answer: D
Rationale: Before assisting the client out of bed, the nurse should first assess the client's blood pressure and pulse. This assessment is crucial to determine the client's physiological stability and readiness for ambulation. It ensures the client's safety during the transfer and helps prevent any potential complications that may arise from getting out of bed. Administering oxygen, lying the client back down, or quickly moving the client to a chair without assessing vital signs can compromise the client's safety and may lead to adverse outcomes.