a male client with rheumatoid arthritis is scheduled for a procedure in the morning the procedure cannot be completed because of early morning stiffne
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Nursing Elites

HESI RN

RN HESI Exit Exam

1. A male client with rheumatoid arthritis is scheduled for a procedure in the morning. The procedure cannot be completed because of early morning stiffness. Which intervention should the nurse implement?

Correct answer: A

Rationale: A warm shower can help reduce morning stiffness, making the procedure more comfortable for the client. This intervention promotes comfort and mobility, addressing the immediate issue of stiffness. Providing a warm blanket (choice B) may offer some comfort but will not address the stiffness as effectively as a warm shower. Delaying the procedure (choice C) may inconvenience the client and not address the underlying stiffness issue. Encouraging range-of-motion exercises (choice D) is important for long-term management but may not provide immediate relief from the stiffness that is hindering the procedure.

2. What is the most important instruction for the nurse to provide a client being discharged following treatment for Guillain-Barre syndrome?

Correct answer: A

Rationale: The most critical instruction for a client being discharged following treatment for Guillain-Barre syndrome is to avoid exposure to respiratory infections. Guillain-Barre syndrome can affect the respiratory system, making infections particularly dangerous. While relaxation exercises, physical therapy, and rest periods are beneficial for overall well-being and recovery, preventing respiratory infections takes precedence due to the potential life-threatening complications associated with respiratory compromise in Guillain-Barre syndrome.

3. In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse (PN)?

Correct answer: D

Rationale: The best client for the charge nurse to assign to a practical nurse (PN) is an older client post-stroke who is aphasic with right-sided hemiplegia. This client is stable and suitable for care by a PN under supervision. Choices A, B, and C present clients with more complex and acute conditions that would require a higher level of nursing expertise and intervention.

4. A client with diabetes mellitus is admitted with a blood glucose level of 640 mg/dl and is unresponsive. Which intervention should the nurse implement first?

Correct answer: B

Rationale: Administering IV fluids as prescribed is the priority intervention in a client with a blood glucose level of 640 mg/dl and unresponsiveness. Severe hyperglycemia can lead to dehydration and electrolyte imbalances, and administering IV fluids can help manage hyperglycemia and prevent further complications. Administering dextrose IV push (Choice A) can exacerbate hyperglycemia in this scenario. Checking the client's blood glucose level (Choice C) is important but not the immediate priority when the client is unresponsive. Immediate dialysis (Choice D) is not indicated as the first intervention for hyperglycemia.

5. Sublingual nitroglycerin is administered to a male client with unstable angina who complains of crushing chest pain. Five minutes later, the client becomes nauseated, and his blood pressure drops to 60/40 mm Hg. Which intervention should the nurse implement?

Correct answer: B

Rationale: The correct intervention in this situation is to infuse a rapid IV normal saline bolus. The client's drop in blood pressure to 60/40 mm Hg after nitroglycerin administration indicates hypotension, which may suggest a right ventricular infarction. Normal saline bolus helps to increase intravascular volume, improve cardiac output, and support blood pressure. Administering a second dose of nitroglycerin would further decrease blood pressure. External chest compressions are not indicated as the client's heart is still beating, and there is no indication for CPR. Giving an antiemetic medication is not the priority in this situation where hypotension is the main concern.

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