a client with cirrhosis is admitted with hepatic encephalopathy which clinical finding is most concerning
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Nursing Elites

HESI RN

HESI RN Exit Exam

1. A client with cirrhosis is admitted with hepatic encephalopathy. Which clinical finding is most concerning?

Correct answer: A

Rationale: Confusion and altered mental status are the most concerning clinical findings in a client with hepatic encephalopathy. These symptoms indicate worsening liver function and potential neurological complications, requiring immediate medical attention. Increased abdominal girth may suggest ascites, yellowing of the skin can indicate jaundice, and peripheral edema may be related to fluid retention, but in the context of hepatic encephalopathy, confusion and altered mental status take precedence due to the risk of rapid deterioration and the need for prompt management.

2. Following routine diagnostic tests, a client who is symptom-free is diagnosed with Paget's disease. Client teaching should be directed toward what important goal for this client?

Correct answer: D

Rationale: In Paget's disease, bone remodeling is affected, leading to increased risk for fractures. Therefore, the primary goal of client teaching should focus on reducing the risk for injury. Choices A and B are not directly related to the primary concern of Paget's disease, which is bone fractures. Choice C, promoting rest and sleep, is important for overall health but is not the priority when considering the specific risks associated with Paget's disease.

3. When organizing home visits for the day, which older client should the home health nurse plan to visit first?

Correct answer: A

Rationale: The correct answer is A. Dark, tarry stools may indicate gastrointestinal bleeding, a potentially life-threatening condition that requires immediate attention. Visiting this client first is crucial for prompt assessment and intervention. Choices B, C, and D do not present immediate life-threatening conditions that require urgent attention compared to the potential emergency indicated by dark, tarry stools.

4. The unit clerk reports to the charge nurse that a healthcare provider has written several prescriptions that are illegible and it appears the healthcare provider used several unapproved abbreviations in the prescriptions. What actions should the charge nurse take?

Correct answer: A

Rationale: The correct action for the charge nurse to take is to call the healthcare provider who wrote the illegible prescriptions. It is crucial to clarify illegible prescriptions directly with the provider to ensure patient safety and prevent medication errors. Option B, attempting to clarify with the pharmacist, may lead to misinterpretation and is not the recommended first step. Administering the medications as prescribed without clarity can jeopardize patient safety, making option C incorrect. Asking another healthcare provider for clarification (option D) may not be effective as the responsibility lies with the provider who wrote the prescription.

5. A client who is at 36 weeks gestation is admitted with severe preeclampsia. After a 6-gram loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate intervention by the nurse?

Correct answer: A

Rationale: A urine output of less than 30 ml/hour indicates that the kidneys are being affected by the high level of magnesium sulfate. This decreased urine output can lead to magnesium toxicity and impaired kidney function. Blood pressure of 138/88 is within normal limits for pregnancy and does not indicate an immediate concern related to magnesium sulfate. A respiratory rate of 18 breaths/min is normal, and a temperature of 99.8°F is slightly elevated but not a priority in the context of severe preeclampsia and magnesium sulfate administration.

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