HESI RN
HESI 799 RN Exit Exam Quizlet
1. A school nurse is called to the soccer field because a child has a nosebleed (epistaxis). In what position should the nurse place the child?
- A. Sitting up and leaning forward
- B. Lying flat with legs elevated
- C. Lying on the side with the head slightly raised
- D. Sitting up and tilting the head back
Correct answer: A
Rationale: The child with a nosebleed (epistaxis) should be placed in a sitting position, leaning forward, to prevent blood from flowing down the throat. This position helps to control the bleeding and prevents the child from swallowing blood, which can cause nausea or vomiting. Choice B is incorrect because elevating the legs is not recommended for nosebleeds. Choice C is incorrect because lying on the side with the head slightly raised is not the optimal position for managing a nosebleed. Choice D is incorrect because tilting the head back can lead to blood flowing down the throat and potentially cause aspiration.
2. The client with a gastric ulcer has a prescription for sucralfate (Carafate), 1 g by mouth four times daily. The nurse schedules the medication for which times?
- A. With meals and at bedtime
- B. Every 6 hours around the clock
- C. One hour after meals and at bedtime
- D. One hour before meals and at bedtime
Correct answer: D
Rationale: Sucralfate is a gastric protectant that forms a protective coating over the ulcer. Administering sucralfate 1 hour before meals and at bedtime is important to create a barrier that protects the ulcer from gastric acid and mechanical irritation. This timing allows sucralfate to effectively coat the ulcer site and provide the desired therapeutic effect, enhancing its efficacy in promoting ulcer healing and symptom relief.
3. A patient with acute congestive heart failure is receiving high doses of a diuretic. On assessment, the nurse notes flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. Suspecting hyponatremia, what additional signs would the nurse expect to note in this patient if hyponatremia were present?
- A. Dry skin
- B. Decreased urinary output
- C. Hyperactive bowel sounds
- D. Increased specific gravity of the urine
Correct answer: C
Rationale: In a patient with hyponatremia, hyperactive bowel sounds are expected due to increased gastrointestinal motility. Dry skin (Choice A) is not a typical sign of hyponatremia. Decreased urinary output (Choice B) is more commonly associated with conditions like dehydration or renal issues, not specifically hyponatremia. Increased specific gravity of the urine (Choice D) is a sign of concentrated urine, which is not a characteristic finding in hyponatremia.
4. What information should the nurse include in the client's health record after a fall in the bathroom?
- A. Client fell while trying to go to the bathroom
- B. The UAP left the client alone and a fall occurred
- C. The client was found on the floor with no pulse
- D. The client fell, sustaining a fracture to the left hip
Correct answer: D
Rationale: The correct answer is D because the nurse should document factual, objective information such as the injury sustained by the client. Reporting the specific injury, like a fracture to the left hip, is crucial for accurate medical records. Choices A, B, and C lack specific detail about the injury and focus on different aspects of the fall that are not as pertinent for the health record. Choice A only mentions the fall without specifying the injury, choice B introduces blame without focusing on the client's condition, and choice C adds unnecessary information about the client's pulse which is not directly related to the fall injury.
5. Several clients on a telemetry unit are scheduled for discharge in the morning, but a telemetry-monitored bed is needed immediately. The charge nurse should make arrangements to transfer which client to another medical unit?
- A. Learning to self-administer insulin injections after being diagnosed with diabetes mellitus
- B. Ambulatory following coronary artery bypass graft surgery performed six days ago
- C. Wearing a sling immobilizer following permanent pacemaker insertion earlier that day
- D. Experiencing syncopal episodes resulting from the dehydration caused by severe diarrhea
Correct answer: A
Rationale: The correct answer is A because transferring a stable client who is learning self-care, such as self-administering insulin injections after being diagnosed with diabetes mellitus, provides the needed telemetry-monitored bed without compromising the client's care. Choice B should not be transferred as the client is ambulatory following surgery and does not require telemetry monitoring. Choice C should not be transferred as the client is wearing a sling immobilizer following pacemaker insertion, which requires close monitoring. Choice D should not be transferred as the client is experiencing syncopal episodes due to severe dehydration, necessitating telemetry monitoring for immediate intervention.