HESI RN
HESI 799 RN Exit Exam
1. A client with a history of hypertension is admitted with a blood pressure of 200/110 mmHg. Which intervention should the nurse implement first?
- A. Administer an antihypertensive medication as prescribed.
- B. Monitor the client's urine output.
- C. Administer oxygen therapy as prescribed.
- D. Obtain an arterial blood gas (ABG) sample.
Correct answer: D
Rationale: The correct answer is to obtain an arterial blood gas (ABG) sample. In a client with severe hypertension, it is essential to assess for metabolic or respiratory acidosis which can be done through an ABG sample. Administering antihypertensive medication without assessing the acid-base status of the client can lead to potential complications. Monitoring urine output and administering oxygen therapy are important interventions but are not the priority in this situation where the focus should be on assessing acidosis.
2. A mother brings her 8-month-old baby boy to the clinic because he has been vomiting and having diarrhea for the last 3 days. Which assessment is most important for the nurse to make?
- A. Assess the infant's abdomen for tenderness
- B. Determine if the infant has been exposed to a virus
- C. Measure the infant’s pulse
- D. Evaluate the infant’s cry
Correct answer: C
Rationale: The most crucial assessment in this scenario is to measure the infant's pulse. Pulse measurement is essential to evaluate the severity of dehydration, which can be a significant concern in a baby experiencing vomiting and diarrhea for several days. Assessing the abdomen for tenderness may provide information on potential causes of symptoms but is not as urgent as monitoring hydration status. Determining exposure to a virus is important for infection control but does not directly address the immediate issue of dehydration. Evaluating the infant's cry, although a form of communication, does not provide critical information regarding the baby's physiological status in this situation.
3. When should a mother introduce solid foods to her 4-month-old baby girl? The mother states, 'My mother says I should put rice cereal in the baby's bottle now.' The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?
- A. Stops rooting when hungry
- B. Opens mouth when food comes her way
- C. Awakens once for nighttime feedings
- D. Gives up a bottle for a cup
Correct answer: B
Rationale: The correct answer is B: 'Opens mouth when food comes her way.' This behavior indicates readiness to start trying solid foods. Infants should be introduced to solid foods based on developmental cues, such as showing an interest in food and the ability to accept it. Choices A, C, and D are not indicative of readiness for solid foods. Stopping rooting when hungry is a reflex that may persist beyond the readiness for solids. Awakening for nighttime feedings is a normal behavior for a 4-month-old, and transitioning from a bottle to a cup is a later developmental milestone.
4. When monitoring a client for acute toxicity associated with bethanechol chloride (Urecholine), what sign should the nurse check for to indicate toxicity?
- A. Dry skin
- B. Dry mouth
- C. Bradycardia
- D. Signs of dehydration
Correct answer: C
Rationale: The correct answer is C: Bradycardia. Toxicity from bethanechol chloride (Urecholine) can lead to excessive muscarinic stimulation, resulting in manifestations like salivation, sweating, involuntary urination and defecation, bradycardia, and severe hypotension. When facing toxicity, treatment involves supportive measures and administering atropine sulfate subcutaneously or intravenously.
5. Ten minutes after signing an operative permit for a fractured hip, an older client states, 'The aliens will be coming to get me soon!' and falls asleep. Which action should the nurse implement next?
- A. Make the client comfortable and allow the client to sleep.
- B. Assess the client's neurologic status.
- C. Notify the surgeon about the comment.
- D. Ask the client's family to co-sign the operative permit.
Correct answer: B
Rationale: The nurse should assess the client's neurologic status next. The client's statement about aliens and subsequent falling asleep could be indicative of a potential neurological issue such as confusion or altered mental status. It is essential to assess the client's neurological status to determine the underlying cause of the client's statement and behavior. This assessment will help the nurse identify any potential cognitive impairment or neurological deficits that may need immediate attention, ensuring the client's safety and well-being. Notifying the surgeon or involving the client's family can be considered later, but the priority is to assess the client's neurologic status to address any immediate concerns.