HESI RN
HESI RN Exit Exam 2024 Quizlet
1. A client with cirrhosis is admitted with jaundice and ascites. Which clinical finding is most concerning?
- A. Increased abdominal girth
- B. Confusion and altered mental status
- C. Yellowing of the skin
- D. Peripheral edema
Correct answer: B
Rationale: Confusion and altered mental status are concerning in a client with cirrhosis as they may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Increased abdominal girth can be seen in ascites, yellowing of the skin is due to jaundice, and peripheral edema is associated with fluid retention in cirrhosis, but confusion and altered mental status are more closely linked to hepatic encephalopathy, which can progress rapidly and needs urgent attention.
2. The nurse is performing a physical assessment of a client with a history of smoking and notes a barrel chest. Which action is most important for the nurse to take next?
- A. Assess the client's oxygen saturation level
- B. Teach the client pursed-lip breathing techniques
- C. Determine the client's history of lung disease
- D. Obtain an arterial blood gas sample
Correct answer: A
Rationale: Corrected Rationale: Assessing the client's oxygen saturation level is crucial when a nurse identifies a barrel chest. A barrel chest is often associated with chronic obstructive pulmonary disease (COPD), which can lead to impaired gas exchange and decreased oxygen saturation. Monitoring the oxygen saturation level will provide immediate information on the client's respiratory status. Teaching pursed-lip breathing techniques, determining lung disease history, and obtaining arterial blood gas samples are important interventions but assessing oxygen saturation takes precedence in this scenario due to its direct impact on the client's respiratory function.
3. A client with chronic kidney disease (CKD) is receiving epoetin alfa (Epogen). Which laboratory value should the nurse monitor closely?
- A. Hemoglobin
- B. White blood cell count
- C. Serum potassium
- D. Serum creatinine
Correct answer: C
Rationale: The correct answer is C: Serum potassium. When a client with chronic kidney disease (CKD) is receiving epoetin alfa (Epogen), monitoring serum potassium levels closely is crucial. Epoetin alfa stimulates red blood cell production, which can lead to an increase in potassium levels. Hyperkalemia is a potential risk in these clients. Monitoring hemoglobin levels (choice A) is important in assessing the effectiveness of epoetin alfa therapy, but it is not the laboratory value that poses an immediate risk related to the medication. White blood cell count (choice B) and serum creatinine (choice D) are not directly affected by epoetin alfa therapy and are not the priority laboratory values to monitor in this case.
4. A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion?
- A. Lung sounds
- B. Urinary output
- C. Peripheral pulses
- D. Peripheral edema
Correct answer: A
Rationale: The correct answer is A: Lung sounds. Hypertonic solutions like 3% NaCl can cause water retention, leading to fluid excess. Monitoring lung sounds is crucial as crackles may indicate pulmonary edema, a serious manifestation of fluid excess. While monitoring urinary output, peripheral pulses, and peripheral edema are also important when administering hypertonic solutions, they do not provide immediate clues to acute respiratory or cardiac decompensation like lung sounds.
5. Following a lumbar puncture, a client complains of worsening headache when sitting up. What complication is the client likely experiencing?
- A. A migraine headache
- B. An infection from the puncture site
- C. Low blood sugar
- D. Spinal fluid leakage (post-lumbar puncture headache)
Correct answer: D
Rationale: The client is likely experiencing spinal fluid leakage (post-lumbar puncture headache), a common complication of a lumbar puncture. This leakage results in a reduction of cerebrospinal fluid volume around the brain and spinal cord, leading to a headache that worsens when in an upright position due to reduced buoyancy. A migraine headache (Choice A) is not typically associated with a lumbar puncture. Infection from the puncture site (Choice B) would present with localized signs of inflammation, such as redness, swelling, and warmth, rather than worsening headache. Low blood sugar (Choice C) is not a common complication of lumbar puncture and would not typically manifest as a worsening headache when sitting up.