HESI RN
HESI RN Exit Exam 2024 Quizlet
1. An older female client tells the nurse that her muscles have gradually been getting weaker. What is the best initial response by the nurse?
- A. Explain that this is an expected occurrence with aging.
- B. Observe the lower extremities for signs of muscle atrophy.
- C. Review the medical record for recent diagnostic test results.
- D. Ask the client to describe the changes that have occurred.
Correct answer: D
Rationale: The best initial response by the nurse when the client reports muscle weakness is to ask the client to describe the changes that have occurred. This approach allows the nurse to gain a better understanding of the client's experience, the extent of weakness, any associated symptoms, and potential triggers. By actively listening to the client's description, the nurse can gather valuable information that will aid in a comprehensive assessment and development of a tailored care plan. Choice A is incorrect because assuming muscle weakness is solely due to aging without further assessment can lead to overlooking potential underlying causes. Choice B is incorrect as observing for signs of muscle atrophy should come after gathering information directly from the client. Choice C is incorrect as reviewing diagnostic test results should not be the initial step when the client's current experience is being shared.
2. The client has syndrome of inappropriate antidiuretic hormone (SIADH). Which intervention is most appropriate?
- A. Encourage increased fluid intake
- B. Administer hypertonic saline
- C. Monitor for signs of dehydration
- D. Restrict oral fluids
Correct answer: D
Rationale: The correct intervention for a client with syndrome of inappropriate antidiuretic hormone (SIADH) is to restrict oral fluids. This is because SIADH leads to excessive production of antidiuretic hormone, causing water retention and dilutional hyponatremia. By restricting oral fluids, the nurse helps prevent further water retention and imbalance of electrolytes. Encouraging increased fluid intake (Choice A) would exacerbate the condition by further increasing fluid retention. Administering hypertonic saline (Choice B) is not the primary treatment for SIADH, as it may worsen the imbalance. Monitoring for signs of dehydration (Choice C) is not appropriate since SIADH leads to water retention, not dehydration.
3. The healthcare professional is preparing to administer a blood transfusion to a client with anemia. Which action is most important to prevent a transfusion reaction?
- A. Check the client's vital signs before starting the transfusion.
- B. Use a blood filter when administering the transfusion.
- C. Verify the blood type and Rh factor with another healthcare professional.
- D. Administer antihistamines before starting the transfusion.
Correct answer: C
Rationale: Verifying the blood type and Rh factor with another healthcare professional is the most crucial action to prevent a transfusion reaction. Ensuring compatibility between the donor blood and the recipient is essential in preventing adverse reactions such as hemolytic transfusion reactions. Checking vital signs is important for monitoring the client during the transfusion process but does not directly prevent a transfusion reaction. Using a blood filter can help remove clots and debris but does not address the risk of a reaction due to blood type incompatibility. Administering antihistamines before the transfusion is not a standard practice to prevent transfusion reactions related to blood type incompatibility.
4. A male client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?
- A. Infusing I.V. fluids rapidly as ordered
- B. Encouraging increased oral intake
- C. Restricting fluids
- D. Administering glucose-containing I.V. fluids as ordered
Correct answer: C
Rationale: The correct nursing intervention for a male client with SIADH is to restrict fluids. In SIADH, there is excess release of antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia. Restricting fluids helps prevent further dilutional hyponatremia by reducing water intake. Infusing I.V. fluids rapidly (choice A) would worsen the condition by adding more fluids, encouraging increased oral intake (choice B) is contraindicated as it adds more fluids, and administering glucose-containing I.V. fluids (choice D) is not a standard treatment for SIADH.
5. A client with a head injury is being monitored for increased intracranial pressure. Which of these findings should be reported to the healthcare provider immediately?
- A. A heart rate of 72 beats per minute
- B. A blood pressure of 110/70 mm Hg
- C. Pupils equal and reactive to light
- D. Client reports headache
Correct answer: C
Rationale: The correct answer is C. Pupils that are equal and reactive to light are a crucial neurological assessment finding. Changes in pupil size and reactivity can indicate increased intracranial pressure, which requires immediate medical attention. Reporting this finding promptly allows for timely intervention to prevent further complications. Choices A, B, and D are within normal ranges and are not indicative of increased intracranial pressure. A heart rate of 72 beats per minute, blood pressure of 110/70 mm Hg, and a client reporting a headache are common findings and may not necessitate immediate intervention in this context.