HESI RN
HESI Fundamentals Quizlet
1. A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement?
- A. Document the client's request in the medical record.
- B. Ask the client if this decision has been discussed with his healthcare provider.
- C. Inform the client that a written, notarized advance directive is required to withhold resuscitation efforts.
- D. Advise the client to designate a person to make healthcare decisions when the client is unable to do so.
Correct answer: B
Rationale: When a client expresses the desire to not be resuscitated, it is essential to inquire if this decision has been discussed with their healthcare provider. This is important to ensure that the client's wishes are appropriately documented and legally binding through the healthcare provider's guidance. It is crucial that healthcare decisions, especially those involving life-saving measures, are well-communicated and documented to respect the client's autonomy and ensure their wishes are honored. Option A is not the best action as it does not address the need to verify discussion with the healthcare provider. Option C is incorrect as it overemphasizes the need for a notarized advance directive, which may not be immediately feasible or necessary in this urgent situation. Option D is not the most appropriate action at this time since the immediate focus should be on clarifying if the decision has been communicated with the healthcare provider.
2. A client who has had two episodes of bacterial cystitis in the last 6 months is being assessed by a nurse. Which questions should the nurse ask? (Select all that apply.)
- A. How much water do you drink every day?
- B. Do you take estrogen replacement therapy?
- C. Does anyone in your family have a history of cystitis?
- D. All of the Above
Correct answer: D
Rationale: The correct answers are all of the above (D). Asking about fluid intake (choice A) is important as it can affect the risk of cystitis. Estrogen levels (choice B) can also impact the likelihood of recurrent cystitis. Family history (choice C) is relevant as certain genetic factors can predispose individuals to cystitis. Cranberry juice, not grapefruit or orange juice, has been found to reduce the risk of bacterial cystitis by increasing the acidic pH. Therefore, choices A, B, and C are all pertinent questions to ask during the assessment of a client with recurrent bacterial cystitis.
3. The nurse is providing care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment finding requires immediate intervention?
- A. Serum sodium of 140 mEq/L.
- B. Serum osmolality of 280 mOsm/kg.
- C. Weight gain of 2 pounds in 24 hours.
- D. Serum sodium of 130 mEq/L.
Correct answer: D
Rationale: The corrected answer is D. A serum sodium level of 130 mEq/L indicates hyponatremia, which requires immediate intervention in a client with SIADH. Hyponatremia can lead to serious complications such as seizures, coma, and cerebral edema. Choices A, B, and C are not the most critical findings in a client with SIADH. While a serum sodium of 140 mEq/L is within the normal range, a decrease to 130 mEq/L is concerning and requires prompt action to prevent complications.
4. A client with a diagnosis of anemia is receiving epoetin alfa (Epogen). Which laboratory test should the nurse monitor to evaluate the effectiveness of this medication?
- A. White blood cell count.
- B. Hemoglobin and hematocrit.
- C. Platelet count.
- D. Blood urea nitrogen (BUN) and creatinine.
Correct answer: B
Rationale: To evaluate the effectiveness of epoetin alfa (Epogen) in treating anemia, the nurse should monitor hemoglobin and hematocrit levels. These values indicate the oxygen-carrying capacity of the blood, which directly relates to the treatment of anemia. White blood cell count (A), platelet count (C), and blood urea nitrogen (BUN) and creatinine (D) are not specific indicators of the effectiveness of epoetin alfa in treating anemia.
5. What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?
- A. Bladder palpation
- B. Inspection of the mouth
- C. Blood glucose monitoring
- D. Auscultation of breath sounds
Correct answer: B
Rationale: The correct answer is B: Inspection of the mouth. This assessment technique is crucial for monitoring gingival hyperplasia, a common side effect of phenytoin. Bladder palpation (choice A) is not relevant to monitoring for phenytoin's side effects. Blood glucose monitoring (choice C) is important for clients with diabetes but is not specifically related to phenytoin. Auscultation of breath sounds (choice D) is more relevant for assessing respiratory conditions, not side effects of phenytoin.