HESI RN
HESI 799 RN Exit Exam Quizlet
1. A client with a nasogastric tube in place following gastric surgery reports nausea. What is the most appropriate nursing action?
- A. Irrigate the NG tube with 30 ml of normal saline.
- B. Administer an antiemetic as prescribed.
- C. Assess the NG tube for patency and reposition if necessary.
- D. Provide sips of water and reassess the client's symptoms.
Correct answer: C
Rationale: Assessing the NG tube for patency and repositioning it if necessary is the most appropriate action to relieve the client's nausea. Nausea in a client with a nasogastric tube can be due to the tube's malposition or blockage. Irrigating the NG tube with normal saline (Choice A) without assessing for patency or repositioning may worsen the situation. Administering an antiemetic (Choice B) can help manage symptoms but does not address the potential issue with the NG tube. Providing sips of water and reassessing symptoms (Choice D) may be contraindicated if there is a problem with the NG tube and could exacerbate the nausea.
2. A community health nurse is planning a program to reduce the incidence of heart disease in the community. Which intervention should the nurse prioritize?
- A. Distributing educational materials on heart-healthy diets
- B. Organizing free cholesterol screenings
- C. Holding workshops on stress management
- D. Partnering with local gyms to offer fitness classes
Correct answer: B
Rationale: The correct answer is B: Organizing free cholesterol screenings. This intervention is crucial because it helps identify individuals at risk for heart disease by assessing their cholesterol levels. High cholesterol is a significant risk factor for heart disease, and identifying it early can lead to timely interventions and medical care. Choices A, C, and D, while beneficial for overall health, may not directly address the specific risk factor of high cholesterol associated with heart disease. Distributing educational materials on heart-healthy diets (A) could be helpful in preventing heart disease, but identifying individuals already at risk is a more urgent need. Holding workshops on stress management (C) and partnering with local gyms for fitness classes (D) are important for overall health promotion but may not target the specific risk factor of high cholesterol as directly as organizing cholesterol screenings.
3. A client is admitted to the ER with DKA. In the acute phase, the priority nursing action is to prepare to:
- A. Administer regular insulin intravenously
- B. Administer 5% dextrose intravenously
- C. Correct the acidosis
- D. Apply an electrocardiogram monitor
Correct answer: A
Rationale: Administering regular insulin intravenously is the priority nursing action in the acute phase of DKA. Insulin helps to lower blood glucose levels by promoting cellular uptake of glucose and inhibiting ketone production. Administering dextrose would be counterproductive as it can worsen hyperglycemia. Correcting acidosis is important but usually follows insulin administration. Applying an electrocardiogram monitor is not the priority action in the acute management of DKA.
4. A client with Herpes Zoster (shingles) on the thorax tells the nurse about having difficulty sleeping. What is the probable cause of this problem?
- A. Frequent cough
- B. Pain
- C. Nocturia
- D. Dyspnea
Correct answer: B
Rationale: The correct answer is B: Pain. Pain is a common and significant symptom of Herpes Zoster (shingles) that can result in difficulty sleeping. The pain associated with shingles can be intense and persistent, making it challenging for the client to find a comfortable position to sleep. Nocturia (choice C), which is excessive urination during the night, is not directly related to difficulty sleeping in this context. While both frequent cough (choice A) and dyspnea (choice D) can cause sleep disturbances, in a client with Herpes Zoster on the thorax, pain is the most probable cause of sleep difficulty.
5. A client with anxiety disorder is experiencing increased anxiety prior to vaginal delivery. What should the nurse’s initial action be?
- A. Increase the client's sedative dose
- B. Encourage the client to express her feelings and provide emotional support
- C. Initiate breathing techniques to manage anxiety
- D. Administer anxiolytic medication to calm the client
Correct answer: B
Rationale: The correct initial action for a client with anxiety disorder experiencing increased anxiety prior to vaginal delivery is to encourage the client to express her feelings and provide emotional support. Emotional support is crucial in reducing anxiety during childbirth. Initiating breathing techniques or administering medications should come after emotional support has been provided. Increasing sedative doses may not address the underlying emotional needs of the client and can have potential risks.