the nurse is caring for a client with chronic kidney disease ckd who is receiving erythropoietin therapy which laboratory value requires immediate int
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Nursing Elites

HESI RN

HESI RN Exit Exam

1. The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value requires immediate intervention?

Correct answer: A

Rationale: A serum potassium level of 5.5 mEq/L is most concerning in a client receiving erythropoietin therapy as it indicates hyperkalemia, requiring immediate intervention. High potassium levels can lead to severe cardiac arrhythmias and must be addressed promptly. The other laboratory values, though abnormal, do not present immediate life-threatening risks as hyperkalemia does.

2. A nurse is preparing to administer a dose of digoxin (Lanoxin) to a client with heart failure. Which assessment finding requires immediate intervention?

Correct answer: A

Rationale: An apical pulse of 58 beats per minute is concerning when administering digoxin because digoxin can further lower the heart rate, leading to bradycardia or heart block. Immediate intervention is required to prevent potential complications. A blood pressure of 110/70 mmHg is within normal range and does not require immediate intervention in this context. The presence of a new murmur may indicate valvular issues but does not directly relate to the administration of digoxin. A respiratory rate of 18 breaths per minute is also within normal limits and is not a priority concern when administering digoxin.

3. In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, the nurse assesses that the client is lethargic with a blood pressure of 90/60, pulse rate of 118 beats per minute, and respiratory rate of 8 breaths per minute. What assessment should the nurse perform next?

Correct answer: D

Rationale: In this scenario, the nurse is dealing with a lethargic client with concerning vital signs after a PCA infusion of morphine sulfate. The next assessment the nurse should perform is to observe the amount and dose of morphine in the PCA pump syringe. This is crucial to evaluate for possible overdose, as the client's symptoms could be indicative of opioid toxicity. Checking the morphine amount and dose will help the nurse adjust the treatment accordingly. Choices A, B, and C do not directly address the potential cause of the client's lethargy and abnormal vital signs related to the morphine infusion.

4. A client with pneumonia has arterial blood gases levels at: pH 7.33; PaCO2 49 mm/Hg; HCO3 25 mEq/L; PaO2 95. What intervention should the nurse implement based on these results?

Correct answer: A

Rationale: The ABG results indicate respiratory acidosis due to an elevated PaCO2 (49 mm/Hg), indicating hypoventilation. The appropriate intervention for respiratory acidosis is to improve ventilation. Coughing and deep breathing protocols can help the client to effectively ventilate and improve gas exchange. Administering oxygen via nasal cannula (Choice B) may be necessary in respiratory distress situations, but addressing the underlying cause of hypoventilation is crucial. Intubation and mechanical ventilation (Choice C) are not the first-line interventions for uncomplicated respiratory acidosis. Increasing IV fluids (Choice D) does not directly address the respiratory acidosis present in this scenario.

5. Following a gunshot wound to the abdomen, a young adult male had an emergency bowel resection and received multiple blood products. His current blood pressure is 78/52 mm Hg, and he is being mechanically ventilated. His oxygen saturation is 87%. Laboratory values indicate hemoglobin of 7 g/dL, platelets of 20,000/mm³, and white blood cells of 2,000/mm³. Which intervention should the nurse implement first?

Correct answer: A

Rationale: The correct answer is to transfuse packed red blood cells first. The client's low hemoglobin level of 7 g/dL indicates severe anemia, which requires immediate transfusion to increase oxygen-carrying capacity. While obtaining blood and sputum cultures (Choice B) is important to identify potential infections, addressing the critical issue of anemia takes precedence. Infusing normal saline (Choice C) may help with volume status but does not address the primary concern of low hemoglobin. Titration of oxygen (Choice D) is crucial, but transfusion to improve oxygen-carrying capacity should be the priority in this scenario.

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