HESI RN
HESI Maternity 55 Questions Quizlet
1. Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8°F (35.8°C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonia, and weak cry. Based on these findings, which action should the nurse implement?
- A. Swaddle the infant in a warm blanket.
- B. Obtain a heel stick blood glucose level.
- C. Place a pulse oximeter on the heel.
- D. Document the findings in the record.
Correct answer: B
Rationale: The assessment findings in the newborn, such as jitteriness, weak cry, and hypotonia, are indicative of potential hypoglycemia. To confirm this suspicion, the nurse should obtain a heel stick blood glucose level, which is the most appropriate action in this situation. Checking the blood glucose level will provide crucial information to determine the newborn's glucose status and guide further management if hypoglycemia is confirmed. Swaddling the infant in a warm blanket does not address the underlying issue of potential hypoglycemia and may not effectively raise the blood glucose level. Placing a pulse oximeter on the heel is not indicated for assessing hypoglycemia. Documenting the findings in the record is important but does not address the immediate concern of assessing and managing potential hypoglycemia.
2. Which of the following is often referred to as the powerhouse of the cell?
- A. Nucleus
- B. Chromatin
- C. Mitochondria
- D. Ribosomes
Correct answer: C
Rationale: Mitochondria are known as the powerhouse of the cell because they generate most of the cell's supply of ATP, which is the energy currency used for various cellular processes. The nucleus (Choice A) is the control center of the cell, housing genetic material. Chromatin (Choice B) is a complex of DNA and proteins within the nucleus. Ribosomes (Choice D) are responsible for protein synthesis and not the primary energy production in the cell.
3. A client with a small bowel obstruction is experiencing frequent vomiting. Which instructions are most important for the nurse to provide to the unlicensed assistive personnel (UAP) who is completing morning care for this client?
- A. Maintain a quiet environment
- B. Ensure the linens are clean and dry
- C. Place an air deodorizer in the room
- D. Measure all emesis accurately
Correct answer: D
Rationale: The correct answer is D, 'Measure all emesis accurately.' When a client with a small bowel obstruction is experiencing frequent vomiting, measuring emesis accurately is crucial for monitoring fluid balance and preventing dehydration. Choice A, 'Maintain a quiet environment,' while important for patient comfort, is not as critical as accurately measuring emesis. Choices B and C, 'Ensure the linens are clean and dry' and 'Place an air deodorizer in the room,' focus on environmental factors that, although helpful, are not as essential as monitoring the client's fluid balance in this situation.
4. In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?
- A. Watery diarrhea
- B. Nausea
- C. Headache
- D. Dizziness
Correct answer: A
Rationale: The correct answer is A: Watery diarrhea. This finding is the most important to report as it may indicate Clostridioides difficile infection, a severe side effect of antibiotic therapy. Clostridioides difficile infection can lead to serious complications and requires immediate medical attention. Choices B, C, and D are common side effects of linezolid but are not as critical as watery diarrhea in this context.
5. The nurse plans to administer a scheduled dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that the client's telemetry pattern shows a second-degree heart block with a ventricular rate of 50. What action should the nurse take?
- A. Administer the Toprol immediately and monitor the client until the heart rate increases.
- B. Provide the dose of Toprol as scheduled and assign a UAP to monitor the client's BP q30 minutes.
- C. Give the Toprol as scheduled if the client's systolic blood pressure reading is greater than 180.
- D. Hold the scheduled dose of Toprol and notify the healthcare provider of the telemetry pattern.
Correct answer: D
Rationale: In clients with second-degree heart block, beta blockers such as metoprolol (Toprol SR) are contraindicated as they can further decrease the heart rate. Administering metoprolol in this situation can lead to serious complications. The correct action for the nurse to take is to hold the scheduled dose of Toprol and promptly notify the healthcare provider of the telemetry pattern. This ensures patient safety and appropriate management of the cardiac condition. Choices A, B, and C are incorrect because administering Toprol despite the heart block can worsen the condition and pose a risk to the client's health.