HESI RN
HESI 799 RN Exit Exam Quizlet
1. A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg PO for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication?
- A. Blood pressure 90/76 mm Hg.
- B. Heart rate of 85 bpm.
- C. Respiratory rate of 20 breaths/minute.
- D. Temperature of 99°F (37.2°C).
Correct answer: A
Rationale: Clonidine can lower blood pressure, so a BP of 90/76 mm Hg may indicate that it is unsafe to administer another dose. In this situation, the low blood pressure reading indicates that the client is already experiencing hypotension, which is a common side effect of clonidine. Administering more clonidine could further lower the blood pressure, leading to potential complications. The heart rate, respiratory rate, and temperature are within normal limits and do not serve as contraindications for administering clonidine in this scenario.
2. A client is receiving a full-strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement?
- A. Add equal amounts of water and feeding to a feeding bag and infuse at 50 ml/hour
- B. Continue the full-strength feeding after decreasing the rate of infusion to 25 ml/hour
- C. Maintain the present feeding until diarrhea subsides and then begin the new prescription
- D. Withhold any further feeding until clarifying the prescription with the healthcare provider
Correct answer: A
Rationale: The correct intervention is to dilute the formula by adding equal amounts of water and feeding to a feeding bag and infusing it at 50 ml/hour. This can help alleviate the diarrhea that has developed. Diarrhea can occur as a complication of enteral tube feeding and can be due to a variety of causes, including hyperosmolar formula. Choice B is incorrect as continuing the full-strength feeding, even at a lower rate, may not address the issue of diarrhea. Choice C is incorrect because it is important to follow the new prescription to manage the diarrhea effectively. Choice D is incorrect as withholding feeding without taking appropriate action may delay necessary intervention.
3. How can menopause affect health?
- A. Causing conjunctivitis
- B. Leading to colitis or bowel upsets
- C. Increasing the risk of cancer
- D. Triggering urinary infections
Correct answer: D
Rationale: Menopause can lead to changes in the urinary tract, such as decreased estrogen levels, which can increase the likelihood of urinary tract infections. While menopause can impact various aspects of health, including bone density and heart health, it is not directly linked to conjunctivitis, colitis, or an increased risk of cancer. Therefore, the correct answer is D.
4. A client being discharged with a prescription for the bronchodilator theophylline is instructed to take three doses of the medication each day. Since timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow?
- A. 9 a.m., 1 p.m., and 5 p.m.
- B. 8 a.m., 4 p.m., and midnight.
- C. Before breakfast, before lunch, and before dinner.
- D. With breakfast, with lunch, and with dinner.
Correct answer: B
Rationale: Theophylline should be administered on a regular around-the-clock schedule to provide the best bronchodilating effect and reduce the potential for adverse effects. The correct dosing schedule of 8 a.m., 4 p.m., and midnight ensures that the client receives consistent dosing throughout the day. Other options do not provide the necessary around-the-clock coverage. It's important to note that food may affect the absorption of the medication, which is why the dosing schedule should not be tied to meal times.
5. In assessing a 9-year-old boy admitted to the hospital with possible acute post-streptococcal glomerulonephritis (APSGN), what information is most significant to obtain in his history?
- A. Back pain for a few days
- B. A history of hypertension
- C. A sore throat last week
- D. Diuresis during the nights
Correct answer: C
Rationale: A recent sore throat is most significant in this case as it could indicate a preceding streptococcal infection, which is a crucial factor in diagnosing APSGN. Streptococcal infection often precedes APSGN, and recognizing this history is essential for appropriate management and treatment. Choices A, B, and D are less relevant in the context of APSGN. Back pain and diuresis are symptoms that may not directly correlate with APSGN, while a history of hypertension, although important in general health assessment, is not as specific to the current scenario compared to a recent sore throat.