HESI RN
HESI Fundamentals Quizlet
1. In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible?
- A. Daily black, sticky stool
- B. Daily dark brown stool
- C. Firm brown stool every other day
- D. Soft light brown stool twice a day
Correct answer: A
Rationale: The correct answer is A: Daily black, sticky stool. Black sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the health care provider promptly. This finding indicates the presence of digested blood in the stool. Choices B, C, and D describe variations of normal stool color and consistency, which do not raise immediate concerns related to gastrointestinal bleeding.
2. The patient is beginning furosemide and has started a 2-week course of a steroid medication. What should the nurse recommend?
- A. Avoid consuming licorice to prevent excess potassium loss.
- B. Report a urine output less than 600 mL/24 hours.
- C. Obtain an order for a potassium supplement.
- D. Take the furosemide in the morning.
Correct answer: C
Rationale: When a patient is taking furosemide and a steroid medication, there is an increased risk of potassium loss due to the interaction between the two drugs. Consuming licorice should be avoided as it can worsen potassium loss. Reporting a urine output less than 600 mL/24 hours is not directly related to the drug interaction and may not be necessary. Taking furosemide at bedtime is not the primary concern when a patient is concurrently on a steroid medication and furosemide. Therefore, obtaining an order for a potassium supplement is the most appropriate recommendation to counteract the potential potassium loss.
3. The nurse is caring for a client who is postoperative following a thyroidectomy. Which finding requires immediate intervention?
- A. Hoarse voice
- B. Slight difficulty swallowing
- C. Positive Chvostek's sign
- D. Pain at the incision site
Correct answer: C
Rationale: A positive Chvostek's sign indicates hypocalcemia, a common complication following thyroidectomy due to inadvertent parathyroid gland injury. Immediate intervention is needed to prevent severe hypocalcemia symptoms like tetany, seizures, and laryngospasm. Hoarse voice and slight difficulty swallowing are expected post-thyroidectomy and do not require immediate intervention. Pain at the incision site is common postoperatively and can be managed with appropriate pain relief measures.
4. A patient presents with severe chest pain radiating to the left arm. Which of the following diagnostic tests is the priority?
- A. Complete blood count (CBC)
- B. Electrocardiogram (ECG)
- C. Chest X-ray
- D. Serum electrolytes
Correct answer: B
Rationale: In a patient presenting with severe chest pain radiating to the left arm, the priority diagnostic test is an Electrocardiogram (ECG) to assess for myocardial infarction. An ECG can quickly identify changes indicative of ischemia or infarction, guiding prompt management. A Complete Blood Count (CBC) may provide some information but is not the primary test for evaluating chest pain related to myocardial infarction. A Chest X-ray can be useful in assessing lung pathologies or certain cardiac conditions; however, it does not provide immediate information on myocardial infarction, making it a secondary option in this scenario. Serum electrolytes may become important in later stages but do not offer immediate insights into myocardial infarction. Therefore, they are a lower priority compared to obtaining an ECG for timely diagnosis and intervention.
5. A client who has been receiving chemotherapy for cancer has a platelet count of 20,000/mm3. Which intervention should the nurse include in the plan of care?
- A. Apply ice packs to bruised areas.
- B. Encourage frequent oral hygiene.
- C. Avoid invasive procedures.
- D. Place the client in a private room.
Correct answer: C
Rationale: The correct intervention for a client with a platelet count of 20,000/mm3 due to chemotherapy is to avoid invasive procedures. Chemotherapy can cause a decrease in platelet count, leading to an increased risk of bleeding. By avoiding invasive procedures, the nurse helps reduce the risk of bleeding complications. Applying ice packs to bruised areas (Choice A) may further increase the risk of bleeding due to the pressure and potential trauma to the skin. Encouraging frequent oral hygiene (Choice B) is important for overall health but does not directly address the risk of bleeding associated with a low platelet count. Placing the client in a private room (Choice D) is not directly related to managing the platelet count and risk of bleeding; it is more about privacy and infection control, which are important but not the priority in this scenario.