HESI RN
Leadership HESI
1. A nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which of the following is part of the plan for preparation and administration of the potassium?
- A. Obtaining a controlled IV infusion pump
- B. Monitoring urine output during administration
- C. Diluting an appropriate amount of normal saline
- D. Preparing the medication for bolus administration
Correct answer: D
Rationale: The correct answer is preparing the medication for bolus administration (Choice D). Potassium should never be administered as a bolus because it can cause cardiac arrest. It must always be diluted and given slowly. Obtaining a controlled IV infusion pump (Choice A) is essential for accurate delivery, monitoring urine output during administration (Choice B) helps assess the client's response, and diluting an appropriate amount of normal saline (Choice C) is necessary to prevent irritation and ensure safe administration.
2. A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling 'very tired'. Which nursing intervention is most important for the nurse to implement?
- A. Measure vital signs
- B. Auscultate breath sounds
- C. Palpate the abdomen
- D. Observe the skin for bruising
Correct answer: A
Rationale: The correct answer is to measure vital signs. Abrupt withdrawal of exogenous corticosteroids can precipitate adrenal insufficiency, potentially leading to shock. Monitoring vital signs is crucial in identifying any signs of adrenal insufficiency, such as hypotension or tachycardia. Auscultating breath sounds (choice B) may be important in other situations, such as respiratory conditions, but it is not the priority in this case. Palpating the abdomen (choice C) and observing the skin for bruising (choice D) are not directly related to the potential complications of corticosteroid withdrawal and adrenal insufficiency.
3. A client is prescribed warfarin (Coumadin) for atrial fibrillation. Which statement by the client indicates a need for further teaching?
- A. I will avoid foods high in vitamin K.
- B. I will take the medication at the same time each day.
- C. I will use an electric razor to shave.
- D. I will take aspirin if I have a headache.
Correct answer: D
Rationale: Clients taking warfarin (Coumadin) should avoid aspirin unless prescribed by their healthcare provider, as it can increase the risk of bleeding. The other statements are correct and do not indicate a need for further teaching. Taking aspirin along with warfarin can potentiate the anticoagulant effects of warfarin, leading to an increased risk of bleeding complications.
4. A client with heart failure is receiving digoxin (Lanoxin) and furosemide (Lasix). Which assessment finding requires immediate intervention?
- A. Heart rate of 60 beats per minute
- B. Apical pulse of 58 beats per minute
- C. Presence of a new murmur
- D. Blood pressure of 100/60 mmHg
Correct answer: C
Rationale: The correct answer is C. The presence of a new murmur in a client with heart failure receiving digoxin and furosemide is concerning as it may indicate valvular problems or other complications that require immediate intervention. A heart rate of 60 beats per minute and an apical pulse of 58 beats per minute are within normal limits for a client with heart failure on these medications. A blood pressure of 100/60 mmHg, while slightly low, may be expected due to the diuretic effect of furosemide and may not require immediate intervention unless the client is symptomatic.
5. What is the most important instruction for the nurse to provide a client with a new colostomy regarding stoma care?
- A. Cleanse the stoma with hydrogen peroxide and water.
- B. Apply a moisture barrier cream to the peristomal skin.
- C. Measure the stoma using a stoma guide.
- D. Use a dry gauze pad to clean the stoma.
Correct answer: C
Rationale: Measuring the stoma using a stoma guide (C) is crucial as it ensures that the appliance fits properly, which is essential for preventing skin irritation and leakage. Proper measurement helps in selecting the right size of the appliance, promoting comfort and optimal stoma care. In contrast, cleansing with hydrogen peroxide (A), applying a moisture barrier cream (B), and using a dry gauze pad (D) are important but not as critical as ensuring the correct fit of the stoma appliance.