HESI RN
HESI RN Nursing Leadership and Management Exam 5
1. The client has received IV solutions for three (3) days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds, the nurse notes the IV site is tender to palpation and a red streak has formed. Which action should the nurse implement first?
- A. Start a new IV in the right hand.
- B. Discontinue the intravenous line.
- C. Complete an incident record.
- D. Place a warm washcloth over the site.
Correct answer: B
Rationale: The first action should be to discontinue the intravenous line to prevent further complications such as infection or thrombophlebitis. Starting a new IV in the right hand is not the priority as addressing the current issue is important. Completing an incident record can be done after addressing the immediate concern of the IV site. Placing a warm washcloth over the site does not address the red streak and tenderness, which may indicate an infection that requires discontinuation of the IV line.
2. Causes of metrorrhagia include:
- A. Cervical carcinoma
- B. Uterine polyp
- C. Cervical endometriosis
- D. Infections like Chlamydia
Correct answer: A
Rationale: Metrorrhagia refers to irregular menstrual bleeding that occurs between periods. Cervical carcinoma, a type of cancer that develops in the cervix, can lead to metrorrhagia. Uterine polyps, which are growths attached to the inner wall of the uterus, can also cause abnormal bleeding. While infections like Chlamydia can cause abnormal vaginal bleeding, they are not common causes of metrorrhagia. Cervical endometriosis, although a possible gynecological condition, is not a typical cause of metrorrhagia. Therefore, the correct answer is cervical carcinoma as it is a known cause of metrorrhagia, making the other options incorrect.
3. What do you call a system involving other government Ministries, Non-Governmental Organizations, Politicians, Policy makers, Senior managers, the Community, Church organizations, and other concerned bodies and users of services?
- A. Community participation
- B. Peer consultation
- C. Multi-sectoral approach
- D. Appropriate technology
Correct answer: C
Rationale: A multi-sectoral approach involves collaboration among various sectors and stakeholders to address complex issues comprehensively. In this context, it ensures that different entities work together to provide inclusive and effective services. Choice A, 'Community participation,' focuses more on the involvement of the community specifically. Choice B, 'Peer consultation,' pertains to seeking advice or input from peers within the same field. Choice D, 'Appropriate technology,' refers to the use of suitable technology for a particular situation, which is not the primary focus of the described system.
4. The nurse is providing discharge teaching to a client with hypertension. Which of these statements made by the client indicates an understanding of the teaching?
- A. I will limit my intake of high-sodium foods.
- B. I will take my medications as prescribed by my healthcare provider.
- C. I will monitor my blood pressure regularly and keep a record to show my healthcare provider.
- D. I will limit my intake of high-fat foods.
Correct answer: A
Rationale: The correct answer is A because limiting high-sodium foods is essential in managing hypertension and preventing complications. High sodium intake can lead to increased blood pressure levels. Choice B is important too, but solely relying on medications without lifestyle modifications may not be as effective in controlling hypertension. Choice C is also crucial for monitoring progress, but without dietary changes, blood pressure control may be challenging. Choice D, limiting high-fat foods, is beneficial for overall health but is not as directly related to managing hypertension as limiting high-sodium foods.
5. The healthcare provider is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?
- A. Positive Babinski reflex.
- B. Flexion of all four extremities.
- C. Heart rate of 220 beats/min.
- D. Cries vigorously when stimulated.
Correct answer: D
Rationale: A vigorous cry upon stimulation indicates that the newborn has good respiratory effort and is transitioning well to life outside the womb. It shows that the infant's airways are clear, and they are able to establish effective breathing, a crucial aspect of transitioning successfully to extrauterine life. Choices A, B, and C are not the best indicators of successful transition to extrauterine life. The Babinski reflex and flexion of extremities are normal neonatal reflexes and do not specifically indicate successful transition. A heart rate of 220 beats/min is abnormally high for a newborn and could indicate distress rather than a smooth transition.