HESI RN
Community Health HESI Quizlet
1. The nurse is assessing an older adult client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?
- A. Ptosis on the left eyelid.
- B. Nystagmus.
- C. Astigmatism.
- D. Exophthalmos.
Correct answer: A
Rationale: The correct answer is A: 'Ptosis on the left eyelid.' Ptosis is the term used to describe an eyelid droop that covers a large portion of the iris, which may be caused by issues with the oculomotor nerve or eyelid muscles. Choice B, 'Nystagmus,' refers to involuntary eye movements and is not related to eyelid drooping. Choice C, 'Astigmatism,' is a refractive error affecting vision due to an irregularly shaped cornea or lens, not an eyelid condition. Choice D, 'Exophthalmos,' is a protrusion of the eyeball associated with conditions like hyperthyroidism, not eyelid drooping.
2. Which of the following molecules acts as the genetic code's messenger?
- A. RNA
- B. Proteins
- C. DNA
- D. Carbohydrates
Correct answer: A
Rationale: The correct answer is RNA. RNA, particularly mRNA, serves as the messenger that carries genetic information from DNA to the ribosome, where proteins are synthesized. Proteins (choice B) are not the genetic code's messenger; they are synthesized based on the information carried by RNA. DNA (choice C) stores the genetic information but does not directly act as the messenger. Carbohydrates (choice D) are not involved in transmitting genetic information.
3. A client receives a prescription for 1 liter of lactated Ringer's intravenously to be infused over 6 hours. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only. If rounding is needed, round to the nearest whole number.)
- A. 167 mL/hr
- B. 200 mL/hr
- C. 83 mL/hr
- D. 111 mL/hr
Correct answer: A
Rationale: The correct infusion rate is 167 mL/hr. This is calculated by dividing the total volume (1000 mL) by the total time (6 hours), resulting in 166.67 mL/hr, which should be rounded to the nearest whole number as 167 mL/hr. This calculation ensures a steady infusion rate over the specified time frame. Choices B, C, and D are incorrect as they do not accurately reflect the correct calculation based on the volume and time provided in the prescription.
4. For a client with peripheral vascular disease (PVD) of the lower extremities who is trying to manage their condition well, which routine should the nurse evaluate as appropriate?
- A. Resting with the legs elevated above the level of the heart.
- B. Walking slowly but steadily for 30 minutes twice a day.
- C. Minimizing activity.
- D. Wearing antiembolism stockings at all times when out of bed.
Correct answer: B
Rationale: The correct answer is B. Walking slowly but steadily for 30 minutes twice a day is appropriate for clients with PVD as it helps stimulate collateral circulation and improve blood flow. Choice A is incorrect because while elevating the legs can help with symptoms temporarily, it is not as effective as walking for improving circulation. Choice C, minimizing activity, is not recommended as it can lead to further deconditioning and worsen symptoms. Choice D, wearing antiembolism stockings, is not specifically indicated for PVD and may not address the underlying circulation issues.
5. The provider has ordered Kayexalate and sorbitol to be administered to a patient. The nurse caring for this patient would expect which serum electrolyte values prior to administration of this therapy?
- A. Sodium 125 mEq/L and potassium 2.5 mEq/L
- B. Sodium 150 mEq/L and potassium 3.6 mEq/L
- C. Sodium 135 mEq/L and potassium 6.9 mEq/L
- D. Sodium 148 mEq/L and potassium 5.5 mEq/L
Correct answer: C
Rationale: Severe hyperkalemia, with a potassium level of 6.9 mEq/L, requires aggressive treatment with Kayexalate and sorbitol to increase the body’s excretion of potassium. The normal range for serum potassium is 3.5 to 5.5 mEq/L, so patients with the other potassium levels would not be treated aggressively or would need potassium supplementation. Therefore, option C (Sodium 135 mEq/L and potassium 6.9 mEq/L) is the correct choice as it indicates severe hyperkalemia warranting the administration of Kayexalate and sorbitol. Options A, B, and D have either potassium levels within normal limits, which would not necessitate this aggressive treatment, or potassium levels that are lower than what would typically prompt the need for Kayexalate and sorbitol.