HESI RN
HESI Quizlet Fundamentals
1. A client with stage 4 lung cancer receiving in-home hospice care expresses concerns about pain while the nurse is arranging for discharge. What action should the nurse take?
- A. Explain the potential respiratory issues associated with morphine use.
- B. Educate the family on assessing the effectiveness of analgesics.
- C. Suggest requesting a patient-controlled analgesic (PCA) pump from the healthcare provider.
- D. Provide the client with a schedule for around-the-clock prescribed analgesic use.
Correct answer: D
Rationale: In managing pain for a client with stage 4 lung cancer in hospice care, providing a schedule for around-the-clock prescribed analgesic use is essential. This approach ensures continuous pain control and helps prevent breakthrough pain. By having a consistent dosing schedule, the client can maintain a more stable level of pain relief, enhancing their comfort and quality of life during this critical time.
2. The nurse is providing care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment finding requires immediate intervention?
- A. Serum sodium of 140 mEq/L.
- B. Serum osmolality of 280 mOsm/kg.
- C. Weight gain of 2 pounds in 24 hours.
- D. Serum sodium of 130 mEq/L.
Correct answer: D
Rationale: The corrected answer is D. A serum sodium level of 130 mEq/L indicates hyponatremia, which requires immediate intervention in a client with SIADH. Hyponatremia can lead to serious complications such as seizures, coma, and cerebral edema. Choices A, B, and C are not the most critical findings in a client with SIADH. While a serum sodium of 140 mEq/L is within the normal range, a decrease to 130 mEq/L is concerning and requires prompt action to prevent complications.
3. A 12-year-old boy has a body mass index (BMI) of 28, a systolic pressure, and a glycosylated hemoglobin (HBA1C) of 7.8%. Which selection indicates that his mother understands the management of his diet?
- A. One whole-wheat bagel with cream cheese, two strips of bacon, six ounces of orange juice.
- B. Two eggs with toast and butter, 8 ounces of milk.
- C. Fresh fruit salad with low-fat yogurt.
- D. Pancakes with syrup and sausage links.
Correct answer: C
Rationale: The correct answer is C. Fresh fruit salad with low-fat yogurt is a healthier choice for managing the diet of a 12-year-old boy with a high BMI and elevated HBA1C. This choice provides a good balance of nutrients, fiber, and low-fat content, helping to lower BMI and maintain healthy blood sugar levels. Choices A, B, and D are less ideal as they contain higher levels of refined carbohydrates, saturated fats, and sugars, which can contribute to weight gain and worsen blood sugar control in this scenario.
4. A client with adrenal insufficiency is admitted to the ICU with acute adrenal crisis. The client's vital signs include heart rate 138 bpm and BP 80/60. What is the nurse's first intervention?
- A. Obtain an analgesic prescription.
- B. Administer an IV fluid bolus.
- C. Administer PRN antipyretic.
- D. Cover the client with a cooling blanket.
Correct answer: B
Rationale: The correct first intervention for a client with adrenal crisis and hypotension is to administer an IV fluid bolus. In adrenal crisis, the body is deficient in cortisol, leading to hypotension. Fluid resuscitation helps stabilize the blood pressure. Obtaining an analgesic prescription (Choice A) is not the priority in this situation. Administering a PRN antipyretic (Choice C) is not indicated as the client's vital signs do not suggest fever. Covering the client with a cooling blanket (Choice D) is not appropriate for addressing hypotension in adrenal crisis.
5. A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family?
- A. The mother is a single parent and lives with her parents
- B. The mother states the baby is irritable during feedings
- C. The infant’s formula has been changed twice
- D. The diaper area shows severe skin breakdown
Correct answer: D
Rationale: Severe skin breakdown in the diaper area is a significant finding indicating a potential health issue that needs immediate attention. It may be a sign of a skin condition, such as a diaper rash, which can cause discomfort and pain for the infant. Addressing this concern promptly is crucial to prevent further complications and ensure the baby's well-being. The other choices may also be important in assessing the overall situation of the family, but in terms of immediate care for the infant, the severe skin breakdown takes priority.