HESI RN
HESI Fundamentals
1. A client with a diagnosis of renal failure is receiving hemodialysis. Which assessment finding should the nurse report to the healthcare provider immediately?
- A. The client's blood pressure is 130/80 mm Hg.
- B. The client gains 1 kg in 24 hours.
- C. The client's potassium level is 5.5 mEq/L.
- D. The client's weight decreases by 0.5 kg in 24 hours.
Correct answer: C
Rationale: A potassium level of 5.5 mEq/L (C) is elevated and concerning in a client with renal failure receiving hemodialysis, as it can lead to life-threatening cardiac arrhythmias. Monitoring blood pressure (A), weight gain (B), and weight loss (D) are essential in clients on hemodialysis, but an elevated potassium level poses an immediate risk that requires prompt intervention.
2. Inevitable abortion occurs when:
- A. The ovum dies in utero and the decidua capsularis remains intact.
- B. The cervix is open, and the products of conception are about to be expelled.
- C. The products of conception are expelled before the 20th week of gestation.
- D. The fetus dies and is expelled in the first trimester.
Correct answer: B
Rationale: Inevitable abortion occurs when the cervix is open, and the products of conception are about to be expelled. This is a critical point in the process of spontaneous abortion, indicating that expulsion of the products of conception is imminent. Choice A is incorrect as it describes a missed abortion where the ovum dies but the decidua capsularis remains intact. Choice C is incorrect as it describes an incomplete abortion where the products of conception are expelled before the completion of 20 weeks of gestation. Choice D is incorrect as it describes a missed abortion where the fetus dies and is expelled in the first trimester.
3. A client with hypertension is prescribed lisinopril (Zestril). Which instruction should the nurse include in the teaching plan?
- A. Avoid foods high in potassium.
- B. Avoid taking the medication with grapefruit juice.
- C. Monitor blood pressure regularly.
- D. Report any swelling of the lips or face.
Correct answer: D
Rationale: The correct instruction for the nurse to include in the teaching plan is to 'Report any swelling of the lips or face.' Lisinopril (Zestril) can cause angioedema, which is swelling of the lips or face. This is a serious side effect that should be reported immediately. Clients do not need to avoid potassium-rich foods unless instructed by their healthcare provider, should avoid taking the medication with grapefruit juice, and should monitor their blood pressure regularly, not just weekly.
4. Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The LPN/LVN knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as
- A. a cephalhematoma, caused by birth trauma and may last up to 8 weeks.
- B. a subarachnoid hematoma, which requires immediate drainage to prevent further complications.
- C. molding, caused by pressure during labor and will disappear within 2 to 3 days.
- D. a subdural hematoma, which can result in lifelong damage.
Correct answer: A
Rationale: Cephalhematoma is the accumulation of blood between the periosteum and skull, often due to birth trauma, and typically resolves within weeks. It is a common finding in newborns and is not usually a cause for concern as it gradually resolves without specific treatment. Subarachnoid hematoma and subdural hematoma are different conditions that present with distinct characteristics and require different management strategies. Therefore, the correct answer is A. Subarachnoid hematoma is typically found in the subarachnoid space and requires immediate intervention, not just observation like cephalhematoma. Molding refers to the shaping of the fetal head during passage through the birth canal and is a temporary change, not a collection of blood like in cephalhematoma. Subdural hematoma is located beneath the dura mater and is associated with significant complications, unlike the self-limiting nature of cephalhematoma.
5. Which of the following is subsidiary uterine support?
- A. Suspensory ligament
- B. Cardinal ligament
- C. Transcervical ligament
- D. Maklouf ligament
Correct answer: B
Rationale: The correct answer is B: Cardinal ligament. The cardinal ligament is a primary uterine support structure that helps to anchor the uterus in place. The suspensory ligament also provides support for the uterus but is not considered a subsidiary uterine support. The transcervical ligament does not exist in anatomical terminology. The Maklouf ligament is a fictitious term and not recognized as a subsidiary uterine support structure.