HESI RN
HESI RN Exit Exam 2024 Quizlet
1. A female client is admitted with end-stage pulmonary disease, is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants 'no heroic measures' taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement?
- A. Ask the client to discuss 'do not resuscitate' with her healthcare provider
- B. Document the client's wishes in her medical record
- C. Ask the client to sign an advance directive
- D. Place a 'Do Not Resuscitate' (DNR) order in the client's chart
Correct answer: A
Rationale: The correct action for the nurse to implement is to ask the client to discuss 'do not resuscitate' (DNR) wishes with her healthcare provider. This is important to ensure that the client makes informed decisions regarding her care. While documenting the client's wishes in her medical record is essential, it is crucial that the client discusses these wishes with the healthcare provider to understand the implications and have the DNR order legally documented. Asking the client to sign an advance directive is premature without a detailed discussion with the healthcare provider. Placing a 'Do Not Resuscitate' (DNR) order in the client's chart should only be done after the client has discussed and agreed upon this decision with the healthcare provider.
2. A mother brings her 3-week-old infant to the clinic because the baby vomits after eating and always seems hungry. Further assessment indicates that the infant’s vomiting is projectile, and the child seems listless. Which additional assessment finding indicates the possibility of a life-threatening complication?
- A. Irregular palpable pulse
- B. Hyperactive bowel sounds
- C. Underweight for age
- D. Crying without tears
Correct answer: D
Rationale: In this scenario, the infant presenting with vomiting, lethargy, and projectile vomiting indicates a potential serious condition. Crying without tears is a sign of dehydration, a critical condition that can lead to life-threatening complications in infants. Dehydration can rapidly worsen an infant's condition, making prompt intervention crucial to prevent further complications. Irregular palpable pulse (Choice A) could indicate a cardiovascular issue but is less immediately life-threatening in this context. Hyperactive bowel sounds (Choice B) are more indicative of gastrointestinal issues rather than a life-threatening complication. Underweight for age (Choice C) may be concerning for growth-related issues but does not directly indicate a life-threatening complication like dehydration does.
3. What is one of the roles of the oxytocin hormone?
- A. Stimulates milk ejection.
- B. Stimulates the production of milk.
- C. Stimulates the development of lactoferrin.
- D. Stimulates the secretion of relaxin.
Correct answer: A
Rationale: The correct answer is A: 'Stimulates milk ejection.' Oxytocin is responsible for contracting the muscles around the milk ducts, pushing milk into the nipples for breastfeeding. This process is known as milk ejection or let-down. The other choices are incorrect because oxytocin's primary function is to facilitate milk ejection rather than directly stimulating the production of milk, the development of lactoferrin, or the secretion of relaxin.
4. The nurse receives an order to give a client iron by deep injection. The nurse knows that the reason for this route is to
- A. enhance absorption of the medication
- B. ensure that the entire dose of medication is given
- C. provide more even distribution of the drug
- D. prevent the drug from tissue irritation
Correct answer: D
Rationale: The correct answer is D. Deep injection helps to prevent tissue irritation caused by iron, which can be damaging to tissues. Option A is incorrect because deep injection does not primarily aim to enhance absorption, but rather to prevent tissue irritation. Option B is incorrect as the route of administration does not determine whether the entire dose is given. Option C is incorrect because the even distribution of the drug is not the main purpose of deep injection in this context.
5. The client is scheduled to begin continuous ambulatory peritoneal dialysis (CAPD). Which of the following statements by the client indicates that more teaching is required?
- A. I will need to limit my intake of protein.
- B. I can skip a dialysis session if I feel tired.
- C. I should increase my intake of potassium-rich foods.
- D. I can eat whatever I want, as long as I take my medications.
Correct answer: B
Rationale: The correct answer is B. Skipping a dialysis session can lead to serious complications as it disrupts the treatment schedule and can result in the accumulation of waste products and fluid in the body. The client must understand the importance of adhering to the prescribed dialysis regimen to maintain optimal health. Choices A, C, and D are incorrect because limiting protein intake, increasing potassium-rich foods, and taking medications do not pose the same risk as skipping dialysis sessions. These aspects are important in the management of peritoneal dialysis but do not outweigh the critical need for regular dialysis sessions to prevent complications.