HESI RN
HESI RN Exit Exam 2024 Quizlet Capstone
1. A client with chronic obstructive pulmonary disease (COPD) presents with a respiratory rate of 32 breaths per minute and an oxygen saturation of 86%. What is the nurse's first action?
- A. Administer oxygen at 2 L/min via nasal cannula.
- B. Notify the healthcare provider immediately.
- C. Position the client in high Fowler's position.
- D. Suction the client's airway.
Correct answer: A
Rationale: Administering oxygen at 2 L/min via nasal cannula is the nurse's first action when a client with COPD presents with a respiratory rate of 32 breaths per minute and an oxygen saturation of 86%. Oxygen therapy helps improve oxygen saturation in patients with COPD and respiratory distress. While notifying the healthcare provider is important, immediate intervention to improve oxygenation takes priority. Positioning the client in high Fowler's position can also assist with breathing but is not the initial action in this scenario. Suctioning the airway is not indicated unless there are secretions obstructing the airway, which is not mentioned in the scenario.
2. A 7-year-old child is admitted to the hospital with nephrotic syndrome. The nurse notes that the child has gained 3 pounds in the past 24 hours. What should the nurse do first?
- A. Administer a diuretic as prescribed
- B. Restrict the child’s fluid intake
- C. Notify the healthcare provider
- D. Measure the child’s abdominal girth
Correct answer: C
Rationale: In a child with nephrotic syndrome experiencing sudden weight gain, the priority action for the nurse is to notify the healthcare provider. This weight gain could indicate worsening edema or fluid retention, necessitating immediate medical evaluation and intervention. The healthcare provider can conduct a comprehensive assessment, order necessary tests, and adjust the treatment plan accordingly. Administering a diuretic, restricting fluid intake, or measuring abdominal girth should not be initiated without healthcare provider consultation to ensure appropriate management of the child's condition.
3. The nurse needs to add a medication to a liter of 5% Dextrose in Water (D5W) that is already infusing into a client. At what location should the nurse inject the medication?
- A. Medication port
- B. IV drip chamber
- C. Y-site connector
- D. At the hub of the IV catheter
Correct answer: A
Rationale: The correct answer is the medication port. When adding medication to an already infusing IV solution, it should be done through the medication port to ensure direct delivery into the bloodstream without interrupting the primary IV line. Injecting the medication into the IV drip chamber, Y-site connector, or at the hub of the IV catheter can lead to dilution, inaccurate dosing, or potential blockages in the IV line, which can compromise the effectiveness of the medication and patient safety.
4. A woman with an anxiety disorder calls her obstetrician's office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman?
- A. Describe the transmission of drugs to the infant through breast milk
- B. Encourage her to use stress-relieving alternatives, such as deep breathing exercises
- C. Inform her that some antianxiety medications are safe to take while breastfeeding
- D. Explain that anxiety is a normal response for the mother of a 3-week-old.
Correct answer: C
Rationale: There are several antianxiety medications that are not contraindicated for breastfeeding mothers, so it is important to inform her of this option.
5. A healthcare professional prepares to reinforce instructions to a client who is taking allopurinol (Zyloprim). The healthcare professional plans to include which of the following in the instructions?
- A. Instruct the client to drink 3000 mL of fluid per day.
- B. Instruct the client to take the medication with food.
- C. Inform the client that the effect of the medication will occur immediately.
- D. Instruct the client that, if swelling of the lips occurs, this is a normal expected response.
Correct answer: A
Rationale: Allopurinol is an antigout medication that works by reducing the production of uric acid in the body. To prevent kidney stones and promote the excretion of uric acid, increased fluid intake is essential. Instructing the client to drink 3000 mL of fluid per day helps to reduce the risk of kidney stones and assists in the elimination of uric acid, thereby enhancing the effectiveness of allopurinol therapy.