HESI RN
Maternity HESI Quizlet
1. A young woman who underwent a liver transplant one year ago tells the clinic nurse that she would like to start a family. How should the nurse intervene?
- A. Provide information about the high-risk nature of her pregnancy.
- B. Gently remind the client that anti-rejection drugs can cause sterility.
- C. Explain the benefits of waiting for a five-year post-transplant period.
- D. Determine if the client is considering options for adopting a child.
Correct answer: A
Rationale: Post-liver transplant pregnancy is high-risk due to potential complications associated with immunosuppressive therapy and the transplanted organ's health. Providing information about the risks involved allows the client to make an informed decision regarding family planning.
2. The nurse instructs the unlicensed nursing personnel (UAP) on how to provide oral hygiene for clients who cannot perform this task for themselves. Which of the following techniques should the nurse tell the UAP to incorporate into the client's daily care?
- A. Assess the oral cavity each time mouth care is given and record observations.
- B. Use a soft toothbrush to brush the client's teeth after each meal.
- C. Swab the client's tongue, gums, and lips with a soft foam applicator every 2 hours.
- D. Rinse the client's mouth with mouthwash several times a day.
Correct answer: B
Rationale: The correct technique to incorporate into the client's daily care for oral hygiene is to use a soft toothbrush to brush the client's teeth after each meal. This helps in maintaining oral hygiene for clients who cannot perform this task themselves. Choice A is incorrect because assessing the oral cavity each time mouth care is given is important but not the technique to incorporate into daily care. Choice C is incorrect as swabbing the tongue, gums, and lips every 2 hours may not be necessary for daily care. Choice D is incorrect as rinsing the client's mouth with mouthwash several times a day may not be suitable for all clients and is not a standard recommendation for daily oral care.
3. A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?
- A. Infuse 5% dextrose in water at 125 mL/hr.
- B. Administer IV morphine sulfate 4 mg every 2 hours PRN.
- C. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.
- D. Administer 3% saline if serum sodium decreases to less than 128 mEq/L.
Correct answer: A
Rationale: The nurse should question the prescription to infuse 5% dextrose in water at 125 mL/hr because the patient's gastric suction has been depleting electrolytes, leading to hyponatremia. Therefore, the IV solution should include electrolyte replacement. Solutions like lactated Ringer’s solution would usually be ordered. The other choices (B, C, and D) are appropriate for a postoperative patient with gastric suction, addressing pain management, nausea control, and correcting hyponatremia if it drops below a certain level.
4. The healthcare provider is caring for a client with a chest tube. Which observation indicates that the chest tube is functioning effectively?
- A. Continuous bubbling in the water-seal chamber.
- B. Intermittent bubbling in the suction control chamber.
- C. No fluctuation (tidaling) in the water-seal chamber.
- D. Drainage of clear, pale yellow fluid from the chest tube.
Correct answer: B
Rationale: Intermittent bubbling in the suction control chamber is the correct observation indicating effective functioning of the chest tube. This bubbling signifies that the suction system is working correctly and maintaining the desired negative pressure in the pleural space. Continuous bubbling in the water-seal chamber suggests an air leak, which is not a normal finding. No fluctuation (tidaling) in the water-seal chamber may indicate a blockage or lack of communication between the pleural space and the water-seal, which is not ideal. Drainage of clear, pale yellow fluid from the chest tube is a normal finding, but it does not specifically indicate the effectiveness of the chest tube function.
5. A 13-year-old client with type 1 diabetes is admitted to the hospital with a blood glucose level of 450 mg/dL. The client is lethargic and has fruity-smelling breath. What is the nurse’s priority action?
- A. Administer insulin as prescribed
- B. Start an IV infusion of normal saline
- C. Check the client’s urine for ketones
- D. Monitor the client’s vital signs
Correct answer: B
Rationale: The correct priority action for the nurse is to start an IV infusion of normal saline. The client's presentation with lethargy, fruity-smelling breath, and high blood glucose level indicates diabetic ketoacidosis (DKA). IV fluids are essential to correct dehydration and help stabilize the client's condition. Checking for ketones in the urine is important, but fluid replacement takes precedence to address the immediate risk of dehydration and electrolyte imbalances. Administering insulin is also a crucial intervention for DKA, but fluid resuscitation should first be initiated.