HESI RN
HESI 799 RN Exit Exam
1. A client with chronic kidney disease (CKD) is admitted with hyperkalemia. Which assessment finding is most concerning?
- A. Bradycardia
- B. Muscle weakness
- C. Peaked T waves on the ECG
- D. Decreased deep tendon reflexes
Correct answer: C
Rationale: The correct answer is C: Peaked T waves on the ECG. In hyperkalemia, elevated potassium levels can affect the heart's electrical activity, leading to changes on the ECG such as peaked T waves. This finding is concerning as it can progress to serious cardiac arrhythmias, including ventricular tachycardia and fibrillation. Bradycardia (choice A) and decreased deep tendon reflexes (choice D) are not typically associated with hyperkalemia. While muscle weakness (choice B) can occur in hyperkalemia due to its effect on neuromuscular function, the most concerning assessment finding indicating the need for immediate intervention in this scenario is peaked T waves on the ECG.
2. Which of the following options identifies the products of cell respiration?
- A. Water, carbon dioxide, and oxygen
- B. Glucose and oxygen
- C. Water, carbon dioxide, and adenosine triphosphate (ATP)
- D. Water, glucose, and oxygen
Correct answer: C
Rationale: The correct answer is C: 'Water, carbon dioxide, and adenosine triphosphate (ATP).' During cellular respiration, glucose is broken down in the presence of oxygen to produce water, carbon dioxide, and ATP. Choice A is incorrect as oxygen is not a product of cell respiration but a reactant. Choice B is incorrect as it lists glucose and oxygen, which are actually reactants in the process. Choice D is incorrect as glucose is not a product of cell respiration but a substrate that is broken down to release energy.
3. The healthcare provider is assessing a client with chronic renal failure who is receiving hemodialysis. Which of the following findings would indicate a complication of the treatment?
- A. Temperature of 98.6°F (37°C).
- B. Weight gain of 2 lbs (0.9 kg) since the last treatment.
- C. Blood pressure of 130/80 mm Hg.
- D. Pulse rate of 72 bpm.
Correct answer: B
Rationale: Weight gain between dialysis sessions can indicate fluid overload, a common complication in clients with chronic renal failure. This can lead to complications such as hypertension, pulmonary edema, and heart failure. A normal temperature, blood pressure, and pulse rate are expected findings in this scenario and would not typically indicate a complication of hemodialysis treatment.
4. The nurse is caring for a client with acute pancreatitis who is reporting severe abdominal pain. Which nursing intervention should the nurse implement first?
- A. Assess the client's bowel sounds
- B. Administer prescribed pain medication
- C. Encourage the client to sit upright
- D. Provide clear fluids to the client
Correct answer: B
Rationale: In a client with acute pancreatitis experiencing severe abdominal pain, the priority nursing intervention is to provide pain relief. Administering prescribed pain medication is essential to improve comfort and reduce pain, which can help stabilize the client's condition. Assessing bowel sounds (Choice A) may be necessary but is not the immediate priority over pain management. Encouraging the client to sit upright (Choice C) and providing clear fluids (Choice D) are not the primary interventions for addressing severe abdominal pain in acute pancreatitis.
5. A client with a history of bipolar disorder is exhibiting symptoms of mania. Which intervention is most appropriate for the nurse to implement?
- A. Encourage the client to participate in group therapy.
- B. Provide a calm and structured environment.
- C. Limit stimulation and set firm limits on behavior.
- D. Promote self-care and hygiene practices.
Correct answer: C
Rationale: When a client with bipolar disorder is experiencing symptoms of mania, the most appropriate intervention for the nurse is to limit stimulation and set firm limits on behavior. This approach helps in managing the manic episode by preventing further escalation. Encouraging participation in group therapy (Choice A) may not be effective during the acute phase of mania, as the client may have difficulty focusing or following group discussions. Providing a calm and structured environment (Choice B) is beneficial, but setting firm limits is crucial to managing the impulsivity and risky behaviors associated with mania. Promoting self-care practices (Choice D) is important, but during a manic episode, setting limits and reducing stimuli take precedence over hygiene practices.