HESI RN
HESI Maternity 55 Questions Quizlet
1. After administering the varicella vaccine to a 5-year-old child, which instruction should the nurse provide the child’s parent?
- A. Chewable children’s aspirin will not help prevent inflammation.
- B. Keep the child home for the next two days.
- C. Any fever should be monitored and reported if severe.
- D. Apply a cool pack to the injection site to reduce discomfort.
Correct answer: D
Rationale: After receiving the varicella vaccine, applying a cool pack to the injection site can help reduce discomfort. This intervention is a simple and effective way to manage local reactions at the site of the vaccination, providing comfort to the child and potentially reducing swelling or pain. Choices A, B, and C are incorrect because chewable children’s aspirin is not typically recommended after vaccination, keeping the child home is not necessary unless advised by a healthcare provider, and monitoring fever alone is not the primary instruction post-varicella vaccination.
2. The RN is preparing medications for a client with bipolar disorder and notices that the client discontinued antipsychotic medication for several days. Which medication should also be discontinued?
- A. Lithium (Lithotabs).
- B. Benztropine (Cogentin).
- C. Alprazolam (Xanax).
- D. Magnesium (Milk of Magnesia).
Correct answer: B
Rationale: The correct answer is Benztropine (Cogentin). Benztropine is commonly prescribed to manage side effects of antipsychotic medications. Therefore, if the antipsychotic medication is discontinued, there would be no need for Benztropine. Lithium is a mood stabilizer used in bipolar disorder, not directly related to antipsychotic use. Alprazolam is an anxiolytic, and Magnesium (Milk of Magnesia) is a laxative, neither of which is typically associated with antipsychotic medication use.
3. A male client with rheumatoid arthritis is scheduled for a procedure in the morning. The procedure cannot be completed because of early morning stiffness. Which intervention should the nurse implement?
- A. Assign a UAP to assist the client with a warm shower early in the morning.
- B. Provide the client with a warm blanket to reduce stiffness.
- C. Delay the procedure until the client is less stiff.
- D. Encourage the client to perform range-of-motion exercises.
Correct answer: A
Rationale: A warm shower can help reduce morning stiffness, making the procedure more comfortable for the client. This intervention promotes comfort and mobility, addressing the immediate issue of stiffness. Providing a warm blanket (choice B) may offer some comfort but will not address the stiffness as effectively as a warm shower. Delaying the procedure (choice C) may inconvenience the client and not address the underlying stiffness issue. Encouraging range-of-motion exercises (choice D) is important for long-term management but may not provide immediate relief from the stiffness that is hindering the procedure.
4. Which of the following would be the priority nursing diagnosis for a client with an ectopic pregnancy?
- A. Risk for infection
- B. Pain
- C. Knowledge Deficit
- D. Anticipatory Grieving
Correct answer: D
Rationale: Anticipatory grieving is the priority nursing diagnosis for a client with an ectopic pregnancy. An ectopic pregnancy is a life-threatening condition that requires immediate medical intervention, often resulting in emotional distress and potential loss. Anticipatory grieving addresses the emotional needs of the client and their family in anticipation of a possible loss. While pain management and infection prevention are important aspects of care, addressing the emotional well-being and coping mechanisms should take precedence in this situation. Knowledge deficit may also be relevant, but emotional support is crucial in this critical scenario.
5. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, the oxygen is running at 6 liters per minute, the client's color is flushed, and his respirations are 8 per minute. What should the nurse do first?
- A. Obtain a 12-lead EKG
- B. Place the client in high Fowler's position
- C. Lower the oxygen rate
- D. Take baseline vital signs
Correct answer: C
Rationale: In a client with COPD, it is crucial to prevent carbon dioxide retention by avoiding high oxygen levels. As the client's oxygen is running at 6 liters per minute and he is showing signs of oxygen toxicity, such as flushed color and low respirations, the nurse's priority should be to lower the oxygen rate. This action helps prevent worsening the client's condition. Obtaining an EKG, placing the client in high Fowler's position, or taking baseline vital signs are important assessments but addressing the potential oxygen toxicity takes precedence in this scenario.