HESI RN
HESI 799 RN Exit Exam Quizlet
1. A client with a history of chronic kidney disease (CKD) is admitted with hyperkalemia. Which assessment finding requires immediate intervention?
- A. Peaked T waves on the ECG
- B. Bradycardia
- C. Decreased deep tendon reflexes
- D. Muscle weakness
Correct answer: A
Rationale: Peaked T waves on the ECG are a critical finding in hyperkalemia as they indicate potential life-threatening cardiac arrhythmias. Immediate intervention is necessary to prevent cardiac complications such as ventricular tachycardia or fibrillation. Bradycardia, decreased deep tendon reflexes, and muscle weakness are not typically associated with hyperkalemia and do not pose the same level of immediate risk to the client's life.
2. A client with a history of adrenal insufficiency is admitted with acute adrenal crisis. The client complains of nausea and joint pain, vital signs show a temperature of 102°F, heart rate of 138, and blood pressure of 80/60. Which intervention should the nurse implement first?
- A. Obtain an analgesic prescription.
- B. Infuse an intravenous fluid bolus.
- C. Administer PRN oral antipyretic.
- D. Cover the client with a cooling blanket.
Correct answer: B
Rationale: In acute adrenal crisis, the priority intervention is to infuse an intravenous fluid bolus to address the hypotension (blood pressure of 80/60) and help stabilize the client's condition. Adequate fluid volume is crucial in managing adrenal insufficiency crisis. Options A, C, and D do not directly address the hypotension and fluid volume depletion that are critical in this situation. Analgesics, antipyretics, and cooling blankets may be considered later, but the immediate focus should be on fluid resuscitation.
3. A client is in the radiology department at 0900 when the prescription for levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement?
- A. Contact the healthcare provider and complete a medication variance form.
- B. Administer the Levaquin at 1300 and resume the 0900 schedule the next day.
- C. Notify the charge nurse and complete an incident report to explain the missed dose.
- D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.
Correct answer: D
Rationale: To maintain a therapeutic level of medication, the nurse should administer the missed dose as soon as possible and adjust the administration schedule to prevent dangerously high levels of the drug in the bloodstream (D). It is important to document the reason for the delayed dose. Contacting the healthcare provider and completing a medication variance form (A) may cause unnecessary delays. Notifying the charge nurse and completing an incident report (C) should be done after addressing the immediate medication administration issue. Administering the medication at 1300 and resuming the 0900 schedule the next day (B) could lead to suboptimal therapeutic levels and potential complications.
4. A nurse has a prescription to insert a nasogastric tube into the stomach of an assigned client. Which action should the nurse take to insert the tube safely and easily?
- A. Placing the tube in warm water
- B. Hyperextending the head while inserting the tube
- C. Removing the tube if any resistance to insertion is met
- D. Asking the client to swallow as the tube is being advanced
Correct answer: D
Rationale: The correct action for the nurse to take to insert a nasogastric tube safely and easily is asking the client to swallow as the tube is being advanced. This action helps facilitate the passage of the tube through the esophagus into the stomach. Placing the tube in warm water (Choice A) is not a recommended practice for nasogastric tube insertion. Hyperextending the head (Choice B) can cause discomfort and is not necessary for safe insertion. Removing the tube if resistance is met (Choice C) is incorrect as it may cause harm or discomfort to the client. Asking the client to swallow helps the tube pass more smoothly and comfortably.
5. Nurse Ronn is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse would expect to find:
- A. Hypotension.
- B. Thick, coarse skin.
- C. Deposits of adipose tissue in the trunk and dorsocervical area.
- D. Weight gain in arms and legs.
Correct answer: C
Rationale: In Cushing's syndrome, the characteristic features include central obesity with deposits of adipose tissue in the trunk and dorsocervical area, often referred to as a 'buffalo hump.' Hypotension (Choice A) is not typically associated with Cushing's syndrome; instead, hypertension is more common. Thick, coarse skin (Choice B) is seen in conditions like hypothyroidism, not specifically in Cushing's syndrome. Weight gain in the arms and legs (Choice D) is not a typical finding in Cushing's syndrome; rather, weight gain is more prominent in the central areas of the body.