a client with a diagnosis of renal failure is receiving hemodialysis which assessment finding should the nurse report to the healthcare provider immed
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Nursing Elites

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?

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. When a student nurse is caught taking a copy of a client's medication administration record to help a friend prepare for the next day's clinical, what should the nurse respond first?

Correct answer: D

Rationale: The correct response when a student nurse is caught taking a copy of a client's medication administration record is to explain that the records are hospital property and cannot be removed. It is essential to educate the student about the confidentiality and security of patient information, emphasizing that even with the client's consent, such actions are unacceptable. Option A is not the immediate action needed, as addressing the student directly should come first. Option B involves notifying another party before addressing the student directly. Option C is incorrect because even if the client gave permission, patient records are confidential and cannot be shared without authorization.

3. The healthcare professional is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the healthcare professional to implement?

Correct answer: A

Rationale: In obtaining a lie-sit-stand blood pressure reading, it is crucial for the healthcare professional to stay with the client while the client is standing. This action is the most important as it ensures client safety during the procedure. Recording findings, keeping the blood pressure cuff on the same arm, and monitoring pulse rate are all important tasks, but staying with the client while standing takes priority to prevent any potential falls or adverse events. By staying with the client, the healthcare professional can promptly address any signs of dizziness or instability, ensuring a safe environment for the client throughout the procedure.

4. After informing an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly expressing a dislike for all healthcare providers and nurses. How should the nurse respond?

Correct answer: C

Rationale: In this situation, the nurse should respond by calmly reassuring the client that the discomfort from the IV insertion will be temporary. By providing reassurance and addressing the client's concerns, the nurse can help reduce the client's apprehension and create a more supportive environment for the procedure.

5. While changing a client’s post-operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given a positive MRSA result, what is the most important action for the nurse to take?

Correct answer: C

Rationale: Initiating contact precautions is crucial in this situation to prevent the spread of MRSA infection. MRSA is a highly contagious bacterium that can spread through direct contact with an infected wound or by touching contaminated surfaces. By implementing contact precautions, the nurse can help contain the infection and protect other patients, healthcare workers, and visitors from being exposed to MRSA.

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