HESI RN
Community Health HESI 2023
1. A client with a history of epilepsy is admitted with status epilepticus. Which medication should the nurse prepare to administer?
- A. Acetaminophen (Tylenol)
- B. Lorazepam (Ativan)
- C. Phenytoin (Dilantin)
- D. Carbamazepine (Tegretol)
Correct answer: B
Rationale: In the management of status epilepticus, the initial medication of choice is a benzodiazepine such as lorazepam (Ativan) to rapidly terminate the seizure activity. Lorazepam acts quickly and effectively in stopping seizures. Phenytoin (Dilantin) is often used as a second-line agent for status epilepticus, and carbamazepine (Tegretol) is not typically indicated for the acute treatment of status epilepticus. Acetaminophen (Tylenol) is a pain reliever and antipyretic but is not used in the treatment of status epilepticus.
2. Which of the following is an expected finding in a patient with hypothyroidism?
- A. Weight gain.
- B. Weight loss.
- C. Increased appetite.
- D. Diarrhea.
Correct answer: A
Rationale: Weight gain is an expected finding in hypothyroidism due to the decreased metabolic rate. Hypothyroidism leads to a slowing down of bodily functions, including metabolism, which can result in weight gain. Weight loss (Choice B) is more commonly associated with hyperthyroidism where there is an increase in metabolic rate. Increased appetite (Choice C) is also more typical of hyperthyroidism as the body is burning energy at a faster rate. Diarrhea (Choice D) is not a typical symptom of hypothyroidism; instead, constipation is more often observed due to the slowing down of the digestive system.
3. The nurse obtains a pulse rate of 89 beats/min for an infant before administering digoxin (Lanoxin). What action should the nurse take?
- A. Administer the medication.
- B. Hold the medication and contact the healthcare provider.
- C. Double the dose.
- D. Increase fluid intake.
Correct answer: B
Rationale: The correct answer is to hold the medication and contact the healthcare provider. Bradycardia (pulse rate less than 100 beats/minute) is an early sign of digoxin toxicity. It is essential to withhold digoxin and notify the healthcare provider to prevent potential adverse effects. Administering the medication (Choice A) could exacerbate the toxicity. Doubling the dose (Choice C) is inappropriate and dangerous. Increasing fluid intake (Choice D) is not indicated in this situation and does not address the issue of digoxin toxicity.
4. The caregiver is caring for a 2-month-old infant with a diagnosis of bronchiolitis. Which assessment finding would be most concerning to the caregiver?
- A. Nasal flaring and grunting
- B. Coughing and wheezing
- C. Poor feeding and irritability
- D. Increased respiratory rate
Correct answer: A
Rationale: Nasal flaring and grunting are indicative of respiratory distress, suggesting the infant is having difficulty breathing. This finding requires immediate attention as it signifies a more severe respiratory compromise compared to the other symptoms listed.
5. What should the nurse do first for a 6-year-old with asthma showing a prolonged expiratory phase, wheezing, and 35% of personal best peak expiratory flow rate (PEFR)?
- A. Administer a prescribed bronchodilator.
- B. Encourage the child to cough and take deep breaths.
- C. Report the findings to the healthcare provider.
- D. Identify the triggers that precipitated this attack.
Correct answer: A
Rationale: Administering a bronchodilator is the priority action in managing an acute asthma exacerbation in a child. Bronchodilators help to relax the muscles around the airways, opening them up and improving breathing. This intervention aims to address the immediate breathing difficulty and should be done promptly to provide relief for the child. Encouraging coughing and deep breaths (choice B) may worsen the child's condition by further constricting the airways. Reporting findings to the healthcare provider (choice C) is important but not the immediate priority in this acute situation. Identifying triggers (choice D) is crucial for long-term asthma management but is not the first step when managing an acute exacerbation.