HESI RN
HESI RN Exit Exam 2024 Quizlet Capstone
1. A client with acute pancreatitis is experiencing severe abdominal pain. Which intervention should the nurse implement to help manage the client's pain?
- A. Encourage deep breathing exercises
- B. Place the client in a side-lying position with knees bent
- C. Administer oral analgesics as prescribed
- D. Encourage the client to take small sips of water
Correct answer: B
Rationale: The correct intervention to help manage the client's pain in acute pancreatitis is to place the client in a side-lying position with knees bent. This position can alleviate abdominal pain by reducing pressure on the pancreas and improving comfort. Encouraging deep breathing exercises (Choice A) is beneficial for other conditions but may not directly help alleviate abdominal pain in pancreatitis. Administering oral analgesics (Choice C) may be necessary but is not the initial priority for managing pain in acute pancreatitis. Encouraging the client to take small sips of water (Choice D) is important for hydration but is not directly related to pain management in this context.
2. A healthcare professional is monitoring the respiratory status of a client who has just undergone surgery and is wearing a pulse oximeter. Which of the following coexisting problems is cause for the healthcare professional to suspect that the oxygen saturation readings are not entirely accurate?
- A. Infection
- B. Hypertension
- C. Low blood pressure
- D. Loss of cough reflex
Correct answer: C
Rationale: Low blood pressure (hypotension), shock, and the use of peripheral vasoconstricting medications can lead to inaccurate pulse oximetry readings due to impaired peripheral perfusion. Hypertension and infection are not typically associated with inaccurate pulse oximetry readings, while the loss of cough reflex does not directly affect oxygen saturation readings.
3. Which of the following are signs and symptoms of vaginitis EXCEPT?
- A. Vaginal itching and irritation
- B. Heavy vaginal bleeding
- C. Pain during coitus
- D. Painful urination
Correct answer: B
Rationale: Vaginitis is characterized by symptoms such as vaginal itching, irritation, pain during coitus, and painful urination. However, heavy vaginal bleeding is not typically associated with vaginitis. Vaginal bleeding could be indicative of other conditions like cervical or endometrial issues, but it is not a common symptom of vaginitis.
4. A client receiving IV heparin reports abdominal pain and tarry stools. What is the nurse's priority action?
- A. Prepare to administer protamine sulfate.
- B. Continue the heparin infusion and notify the healthcare provider.
- C. Monitor the client's vital signs and assess abdominal pain.
- D. Administer a PRN dose of morphine sulfate.
Correct answer: A
Rationale: The correct answer is to prepare to administer protamine sulfate. Abdominal pain and tarry stools are indicative of gastrointestinal bleeding, a serious side effect of heparin therapy. Protamine sulfate is the antidote for heparin and is used to reverse its effects in cases of bleeding. Continuing the heparin infusion (Choice B) is not appropriate when the client is experiencing signs of bleeding. Monitoring vital signs and assessing abdominal pain (Choice C) is important but not the priority when immediate action is required to address potential bleeding. Administering morphine sulfate (Choice D) is not the priority in this situation; addressing the underlying cause of bleeding takes precedence.
5. A client with acute kidney injury has an elevated creatinine level. What is the nurse's priority intervention?
- A. Administer diuretics as prescribed.
- B. Prepare the client for dialysis.
- C. Restrict the client’s fluid intake.
- D. Notify the healthcare provider immediately.
Correct answer: B
Rationale: The correct answer is B: Prepare the client for dialysis. Clients with acute kidney injury and elevated creatinine may require dialysis to support kidney function and remove waste products from the blood. Preparing for dialysis ensures timely intervention in preventing further complications. Administering diuretics (Choice A) may worsen the client's condition by further compromising kidney function. Restricting fluid intake (Choice C) may be necessary in some cases, but it is not the priority over preparing for dialysis. Notifying the healthcare provider (Choice D) is important, but the immediate priority is to prepare for dialysis to address the acute kidney injury and elevated creatinine level.