a male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm a stat 12 lead electrocardiogram ecg
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Nursing Elites

HESI RN

RN HESI Exit Exam

1. A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, III, aVF, and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement?

Correct answer: B

Rationale: Assessing for contraindications for thrombolytic therapy is crucial as it determines whether the client is a candidate for reperfusion therapy. In this scenario, the client is presenting with symptoms and ECG changes consistent with an acute myocardial infarction (MI). Thrombolytic therapy aims at restoring blood flow to the heart muscle, reducing the size of the infarct. However, it is essential to assess for contraindications such as recent surgery, active bleeding, or a history of stroke to avoid potential complications. Obtaining serum cardiac biomarkers or measuring ST-segment changes are important steps in the diagnosis of MI but are not as time-sensitive as assessing for contraindications to thrombolytic therapy. Transfer for percutaneous coronary intervention (PCI) is a definitive treatment for MI, but assessing for thrombolytic therapy eligibility takes precedence in this acute situation.

2. A woman who takes pyridostigmine for myasthenia gravis (MG) arrives at the emergency department complaining of extreme muscle weakness. Her adult daughter tells the nurse that since yesterday her mother has been unable to smile. Which assessment finding warrants immediate intervention by the nurse?

Correct answer: A

Rationale: Uncontrollable drooling can be a sign of a myasthenic crisis, which requires immediate medical intervention to prevent respiratory failure. Drooling indicates difficulty in swallowing, which can lead to aspiration and respiratory compromise. Inability to raise voice (choice B) and tingling of extremities (choice C) are not typically associated with myasthenic crisis. Although eyelid drooping (choice D) is a common symptom of myasthenia gravis, it is not as urgent as uncontrollable drooling in indicating a potential crisis.

3. A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which intervention should the nurse implement first?

Correct answer: D

Rationale: The correct answer is to administer 50% dextrose IV push first. In hyperglycemic hyperosmolar syndrome, the main goal is to rapidly reduce blood glucose levels to prevent further complications. Administering dextrose intravenously can help reverse the effects of high blood glucose levels quickly. Administering intravenous fluids, monitoring urine output, and obtaining a blood glucose level are important interventions but are not the first priority in treating HHS. Administering 50% dextrose IV push takes precedence as it directly addresses the elevated blood glucose levels.

4. Following a lumbar puncture, a client voices several complaints. What complaint indicates to the nurse that the client is experiencing a complication?

Correct answer: D

Rationale: The correct answer is D. A post-lumbar puncture headache, ranging from mild to severe, may occur as a result of leakage of cerebrospinal fluid at the puncture site. This complication is usually managed by bed rest, analgesics, and hydration. Choices A, B, and C do not directly indicate complications associated with a lumbar puncture. Pain in the lower back when moving legs, a sore throat when swallowing, and nausea with a feeling of vomiting are not typical complications of lumbar puncture.

5. 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.

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