HESI RN
HESI 799 RN Exit Exam Quizlet
1. A nurse is preparing to administer a dose of digoxin (Lanoxin) to a client with heart failure. Which assessment finding requires immediate intervention?
- A. Apical pulse of 58 beats per minute
- B. Blood pressure of 110/70 mmHg
- C. Presence of a new murmur
- D. Respiratory rate of 18 breaths per minute
Correct answer: A
Rationale: An apical pulse of 58 beats per minute is concerning when administering digoxin because digoxin can further lower the heart rate, leading to bradycardia or heart block. Immediate intervention is required to prevent potential complications. A blood pressure of 110/70 mmHg is within normal range and does not require immediate intervention in this context. The presence of a new murmur may indicate valvular issues but does not directly relate to the administration of digoxin. A respiratory rate of 18 breaths per minute is also within normal limits and is not a priority concern when administering digoxin.
2. What is the typical measurement of the anterior wall of the vaginal canal?
- A. 10 cm
- B. 11 cm
- C. 11.5 cm
- D. 7.5 cm
Correct answer: D
Rationale: The typical measurement of the anterior wall of the vaginal canal is 7.5 cm. This measurement is anatomically accurate, making choice D the correct answer. Choices A, B, and C provide measurements that are larger than the typical measurement of the anterior wall of the vaginal canal and are therefore incorrect.
3. A client with a history of heart failure is admitted with severe dyspnea. Which laboratory result requires immediate intervention?
- A. Blood glucose of 150 mg/dL.
- B. Serum potassium of 3.5 mEq/L.
- C. Serum creatinine of 1.0 mg/dL.
- D. Blood urea nitrogen (BUN) of 20 mg/dL.
Correct answer: C
Rationale: The correct answer is C. A serum creatinine level of 1.0 mg/dL is within the normal range. However, in a client with heart failure and severe dyspnea, fluid retention is a significant concern. An elevated serum creatinine level may indicate impaired kidney function, which can worsen fluid overload. Therefore, immediate intervention is required to prevent further complications. Choices A, B, and D are within normal ranges and not indicative of immediate intervention in this scenario.
4. A client is receiving intravenous antibiotics for the treatment of a severe infection. Which of these assessments is a priority for the nurse to perform?
- A. Monitor the client's temperature
- B. Assess the client's pain level
- C. Check the intravenous (IV) site for signs of phlebitis
- D. Monitor the client's respiratory status
Correct answer: C
Rationale: When a client is receiving intravenous antibiotics, checking the IV site for signs of phlebitis is a priority assessment for the nurse. Phlebitis is an inflammation of the vein, which can lead to serious complications such as infection and thrombosis. Monitoring the IV site helps prevent these complications and ensures the safe delivery of antibiotics. While monitoring the client's temperature, pain level, and respiratory status are important assessments, they are not the priority in this scenario where IV antibiotic administration requires close monitoring for complications like phlebitis.
5. A client with a history of type 1 diabetes Mellitus (DM) and asthma is readmitted to the unit for the third time in two months with a current fasting blood sugar (FBS) of 325mg/dl (18mmol/L SI). The client describes to the nurse not understanding why the blood glucose level continues to be out of control. Which interventions should the nurse implement?
- A. Have the client describe a typical day at work, home, and social activities
- B. Determine if the client is using a new insulin needle for each administration
- C. Evaluate the client's asthma medications that can elevate blood glucose
- D. Have the client demonstrate the technique used to monitor blood glucose levels
Correct answer: A
Rationale: The correct answer is to have the client describe a typical day at work, home, and social activities. By understanding the client's daily routine, the nurse can gain valuable insights into lifestyle factors that may be impacting blood glucose control. This information is essential for identifying potential triggers or patterns contributing to the elevated blood sugar levels. Option B, determining if the client is using a new insulin needle for each administration, focuses more on the technical aspect of insulin delivery and is not directly related to daily activities affecting blood glucose levels. Option C, evaluating the client's asthma medications that can elevate blood glucose, could be relevant but is not as directly linked to the client's lifestyle choices as option A. Option D, having the client demonstrate the technique for monitoring blood glucose levels, is important for assessing their skills but does not provide information on daily activities that may be influencing blood sugar levels.