HESI RN
HESI RN Exit Exam 2024 Quizlet
1. A client with a spinal cord injury at the T1 level is admitted with a suspected deep vein thrombosis (DVT) in the right leg. Which intervention should the nurse implement first?
- A. Administer prescribed anticoagulant therapy
- B. Place the client on bedrest
- C. Elevate the client's right leg
- D. Apply compression stockings to the right leg
Correct answer: B
Rationale: The correct answer is to place the client on bedrest. Placing the client on bedrest is the priority intervention as it helps prevent the risk of embolization from the DVT, which could lead to a life-threatening pulmonary embolism. Administering anticoagulant therapy, elevating the client's right leg, or applying compression stockings are important interventions in managing DVT but should come after ensuring the client is on bedrest to prevent the dislodgment of the clot.
2. The nurse is caring for a 17-year-old male who fell 20 feet 5 months ago while climbing the side of a cliff and has been in a sustained vegetative state since the accident. Which intervention should the nurse implement?
- A. Talk directly to the adolescent while providing care
- B. Maintain silence during care to avoid overstimulation
- C. Play soothing music in the background
- D. Limit visitors to immediate family only
Correct answer: A
Rationale: Talking directly to the adolescent is the most appropriate intervention in this scenario. It helps maintain a sense of connection and respect, even if the response is not evident. Maintaining silence may lead to isolation and hinder any potential communication attempts. Playing soothing music may not provide the personal interaction needed for connection. Limiting visitors to immediate family only may deprive the patient of diverse interactions that could be beneficial for their emotional well-being.
3. When examining sources for funding, which criteria should the nurse clarify about the program for the community group?
- A. a prescription from the healthcare provider for each visit made
- B. documentation of a skilled care service provided during the visit
- C. a copy of the client's health history and social security card
- D. a record of the preventive healthcare services provided during the visit
Correct answer: C
Rationale: The correct answer is C because when seeking funding sources for a community outreach program, it is essential to clarify aspects related to the client's personal information, such as health history and identification details. This information helps in demonstrating the need for the program and understanding the target population. Choices A, B, and D are incorrect because they focus on clinical documentation, services provided during visits, and preventive healthcare services, which are not directly related to clarifying funding criteria about the program.
4. A client with rheumatoid arthritis is prescribed methotrexate. Which assessment finding requires immediate intervention?
- A. Fever of 100.4°F
- B. Positive Chvostek's sign
- C. Increased joint pain
- D. Swelling in the joints
Correct answer: B
Rationale: A positive Chvostek's sign indicates hypocalcemia, which requires immediate intervention as it can lead to life-threatening complications. Fever, increased joint pain, and swelling in the joints are common symptoms in clients with rheumatoid arthritis but do not require immediate intervention like addressing hypocalcemia.
5. Prior to surgery, written consent must be obtained. What is the nurse's legal responsibility with regard to obtaining written consent?
- A. Witness the consent and sign the form as a witness
- B. Inform the client of alternatives to the procedure
- C. Explain the procedure in detail to the client
- D. Determine that the surgical consent form has been signed and is included in the client's record
Correct answer: D
Rationale: The nurse's legal responsibility is to ensure that informed consent has been obtained by verifying that the client has signed the form and that it is included in the record. Witnessing the consent and signing as a witness is not the nurse's role, as this is typically done by a neutral party. Informing the client of alternatives to the procedure and explaining the procedure in detail are responsibilities of the healthcare provider performing the surgery, not the nurse.