HESI RN
HESI RN Exit Exam 2024 Quizlet Capstone
1. After a spider bite on the lower extremity, a client is admitted to treat an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider?
- A. Swollen lymph nodes in the groin
- B. Core body temperature of 100.5°F
- C. All of the above
- D. Elevated white blood cell count
Correct answer: C
Rationale: All of the above findings should be reported to the healthcare provider for prompt evaluation and treatment. Swollen lymph nodes in the groin indicate regional lymphatic involvement, a core body temperature of 100.5°F suggests a mild fever response, and an elevated white blood cell count indicates an ongoing infection process. These findings collectively point towards the spread of infection and require immediate attention to prevent further complications.
2. A two-year-old child with heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse take?
- A. Determine the pulse deficit
- B. Administer the scheduled dose
- C. Calculate the safe dose range
- D. Review the serum digoxin level
Correct answer: B
Rationale: The correct action for the nurse to take is to administer the scheduled dose of digoxin. A heart rate of 128 bpm in a two-year-old child with heart failure falls within the safe range for digoxin administration. It indicates that the child's heart rate is not excessively low, which could be a concern for administering digoxin. Therefore, proceeding with the scheduled dose is appropriate in this scenario. Determining the pulse deficit (Choice A) is not necessary in this situation as the heart rate is already obtained. Calculating the safe dose range (Choice C) is not required as the heart rate is within the safe range. Reviewing the serum digoxin level (Choice D) is not needed at this point since the heart rate indicates that administering the next dose is appropriate.
3. The client has been taking omeprazole (Prilosec) for 4 weeks. The ambulatory care nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom?
- A. Diarrhea
- B. Heartburn
- C. Flatulence
- D. Constipation
Correct answer: B
Rationale: Omeprazole, a proton pump inhibitor, is used as an antiulcer agent to reduce gastric acid secretion. The optimal intended effect of omeprazole is the relief of pain and discomfort associated with gastric irritation, commonly referred to as heartburn. Therefore, the absence of heartburn indicates that the medication is working effectively in managing the client's gastric condition.
4. One hour after delivery, the nurse is unable to palpate the uterine fundus of a client and notes a large amount of lochia on the perineal pad. Which intervention should the nurse implement first?
- A. Empty the bladder using an indwelling urinary catheter
- B. Increase the rate of the IV containing oxytocin (Pitocin)
- C. Assess for shock by determining the blood pressure
- D. Perform gentle massage at the level of the umbilicus
Correct answer: D
Rationale: Gentle massage at the level of the umbilicus is the initial intervention to help contract the uterus and reduce bleeding, which is crucial in managing postpartum hemorrhage. Emptying the bladder can help with fundal displacement, but massage should be done first to stimulate uterine contractions. Increasing the IV oxytocin rate is a possible intervention but not the initial priority. Assessing for shock is important, but addressing the uterine atony through massage takes precedence to prevent further hemorrhage.
5. A nurse is preparing to administer NPH insulin to a client with DM. The nurse notes that the NPH insulin vial is cloudy. The nurse should:
- A. Obtain a new vial of NPH insulin.
- B. Draw up the cloudy insulin as ordered.
- C. Shake the vial vigorously before drawing up the insulin.
- D. Warm the insulin to room temperature before administration.
Correct answer: B
Rationale: The correct answer is to draw up the cloudy insulin as ordered. NPH insulin is inherently cloudy due to its suspension of insulin crystals. Shaking the vial vigorously can lead to denaturation of the insulin molecules, altering its efficacy. Warming NPH insulin is not necessary as it can cause breakdown of insulin molecules. The nurse should gently roll the vial between hands to mix it before drawing it up to ensure an even distribution of insulin in the suspension.