HESI RN
HESI 799 RN Exit Exam Quizlet
1. A client with heart failure who is on a low sodium diet reports a weight gain of 2 kg in 24 hours. Which intervention should the nurse implement first?
- A. Instruct the client to reduce fluid intake
- B. Monitor the client's intake and output
- C. Administer a diuretic as prescribed
- D. Assess the client for signs of fluid overload
Correct answer: D
Rationale: The correct first intervention for a client with heart failure who is on a low sodium diet and reports a significant weight gain is to assess the client for signs of fluid overload. This step is crucial in determining the severity of the situation and guiding further treatment. In this scenario, assessing for signs of fluid overload takes priority over other actions such as instructing the client to reduce fluid intake, monitoring intake and output, or administering a diuretic. While these actions may be necessary depending on the assessment findings, the initial priority is to evaluate the client's immediate condition.
2. The client, who is 6 weeks pregnant, is being educated by the nurse on prenatal care. Which statement indicates that the client comprehends the nurse's instructions?
- A. I will increase my intake of vitamin C.
- B. I will avoid alcohol and tobacco.
- C. I will need to take folic acid supplements.
- D. I will avoid taking any medication without consulting my healthcare provider.
Correct answer: D
Rationale: The correct answer is D. During pregnancy, it is crucial to avoid taking any medication without consulting a healthcare provider to prevent harm to the developing fetus. Choices A, B, and C are important aspects of prenatal care but do not specifically address the potential risks associated with taking medications during pregnancy. Increasing intake of vitamin C (Choice A) is beneficial but does not address medication safety. Avoiding alcohol and tobacco (Choice B) is essential, but the question focuses on medication safety. Taking folic acid supplements (Choice C) is vital for neural tube development but does not cover the broader topic of medication safety.
3. The healthcare provider is assessing a client with chronic obstructive pulmonary disease (COPD). Which finding requires immediate intervention?
- A. Oxygen saturation of 88%.
- B. Use of accessory muscles for breathing.
- C. Respiratory rate of 26 breaths per minute.
- D. Barrel-shaped chest.
Correct answer: C
Rationale: A respiratory rate of 26 breaths per minute is an abnormal finding and indicates that the client is experiencing respiratory distress, requiring immediate intervention. This rapid respiratory rate can signify inadequate oxygenation and ventilation. Oxygen saturation of 88% is low but not as immediately concerning as a high respiratory rate, which indicates the body is compensating for respiratory distress. The use of accessory muscles for breathing and a barrel-shaped chest are typical findings in clients with COPD but do not indicate an immediate need for intervention as they are more chronic in nature and may be seen in stable COPD patients.
4. When reinforcing teaching with the parents of a 7-year-old child with attention-deficit/hyperactivity disorder (ADHD) about the child's medication, which statement by the parents indicates an understanding of the medication's side effects?
- A. We should monitor our child's growth and appetite regularly.
- B. The medication may cause drowsiness, so we will give it at bedtime.
- C. We need to give the medication with food to avoid stomach upset.
- D. The medication can cause increased urination, so fluid intake should be limited.
Correct answer: A
Rationale: The correct answer is A: 'We should monitor our child's growth and appetite regularly.' Correct monitoring of the child's growth and appetite is crucial when a child is on ADHD medications, especially stimulants, as these medications can have side effects related to growth and appetite. Monitoring these parameters regularly helps in assessing the medication's impact and making any necessary adjustments. Choices B, C, and D are incorrect: B talks about drowsiness, C mentions avoiding stomach upset, and D refers to increased urination and limiting fluid intake. While these are potential side effects of medications, they do not directly address the importance of monitoring growth and appetite, which is crucial in children on ADHD medications.
5. A female client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What should the nurse do first?
- A. Offer the client a safe place to relax before interviewing her.
- B. Ask the client to describe why she is being stalked.
- C. Recommend that the client talk with a social worker.
- D. Assure the client that the healthcare provider will see her today.
Correct answer: A
Rationale: When a client presents with signs of distress and potential safety concerns, the priority is to provide a safe environment. Offering a safe place to relax can help the client feel secure and ready for further assessment and support. This action allows the nurse to establish rapport, ensure the client's immediate safety, and create a trusting relationship before delving into the details of the situation. Asking the client to describe why she is being stalked (Choice B) may exacerbate her distress and should come after ensuring her safety. Recommending that the client talk with a social worker (Choice C) is important but should follow immediate safety measures. Assuring the client that the healthcare provider will see her today (Choice D) is less critical than addressing her safety concerns and emotional state.