HESI RN
HESI RN Exit Exam 2024 Quizlet
1. A client with a history of chronic kidney disease (CKD) is receiving erythropoietin therapy. Which laboratory value should the nurse monitor closely?
- A. Serum potassium level
- B. White blood cell count
- C. Hemoglobin level
- D. Serum calcium level
Correct answer: A
Rationale: The correct answer is A: Serum potassium level. In a client receiving erythropoietin therapy for chronic kidney disease, monitoring serum potassium levels is crucial due to the risk of hyperkalemia. Erythropoietin can stimulate red blood cell production, leading to an increased demand for potassium. Monitoring potassium levels helps prevent complications associated with hyperkalemia. Choices B, C, and D are incorrect because erythropoietin therapy specifically impacts potassium levels, not white blood cell count, hemoglobin level, or serum calcium level.
2. A client is experiencing shortness of breath and wheezing. What is the nurse's first action?
- A. Administer bronchodilator medication
- B. Check the client's oxygen saturation
- C. Encourage the client to use pursed-lip breathing
- D. Elevate the head of the bed
Correct answer: A
Rationale: Administering a bronchodilator is the priority intervention to open the airways and relieve wheezing and shortness of breath. Bronchodilators work quickly to dilate the airways, making it easier for the client to breathe. Checking oxygen saturation is important but can be done after initiating bronchodilator therapy. Encouraging pursed-lip breathing and elevating the head of the bed can help improve breathing patterns but should follow the administration of the bronchodilator.
3. To prevent unnecessary hypoxia during suctioning of a tracheostomy, what must the nurse do?
- A. Apply suction for no more than 10 seconds
- B. Maintain sterile technique
- C. Lubricate 3 to 4 inches of the catheter tip
- D. Withdraw catheter in a circular motion
Correct answer: A
Rationale: The correct answer is to apply suction for no more than 10 seconds. Prolonged suctioning can lead to hypoxia, so it is essential to limit the suctioning time. Maintaining sterile technique (choice B) is important to prevent infections but is not directly related to preventing hypoxia during suctioning. Lubricating the catheter tip (choice C) helps with insertion but does not specifically address hypoxia prevention. Withdrawing the catheter in a circular motion (choice D) is not a standard practice during tracheostomy suctioning and does not help prevent hypoxia.
4. The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm, and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?
- A. Urinary output and fluid intake.
- B. Hemoglobin and hematocrit.
- C. Abdominal contour and bowel sounds.
- D. Heart rate and blood pressure.
Correct answer: D
Rationale: In a postpartum client with a perineal hematoma, assessing heart rate and blood pressure is crucial as it can help determine the client's circulatory status. A perineal hematoma has the potential to cause significant blood loss leading to hypovolemia. Monitoring vital signs like heart rate and blood pressure can provide immediate information on the client's hemodynamic stability and guide further interventions if needed.
5. A client with diabetes mellitus has a blood glucose level of 350 mg/dL. Which of these actions should the nurse take first?
- A. Administer insulin as ordered
- B. Encourage the client to drink fluids
- C. Notify the healthcare provider
- D. Recheck the blood glucose level in 30 minutes
Correct answer: A
Rationale: Administering insulin as ordered is the priority action when a client with diabetes mellitus has a blood glucose level of 350 mg/dL. Insulin helps to lower the high blood glucose level and prevent complications such as diabetic ketoacidosis. Encouraging the client to drink fluids may be beneficial but does not address the immediate need to lower the blood glucose level. Notifying the healthcare provider and rechecking the blood glucose level can be important steps but should come after administering insulin to address the high glucose level promptly.