HESI RN
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1. The nurse is caring for a client with chronic renal failure who is on a low-potassium diet. Which of the following foods should the client avoid?
- A. Bananas
- B. Potatoes
- C. Rice
- D. Apples
Correct answer: A
Rationale: Bananas are high in potassium content, which can lead to hyperkalemia in clients with chronic renal failure who are on a low-potassium diet. Therefore, it is crucial for these clients to avoid bananas. Potatoes, rice, and apples are lower in potassium compared to bananas and are generally considered safe for consumption in clients with chronic renal failure on a low-potassium diet.
2. What is the priority intervention for a patient with a suspected myocardial infarction (MI)?
- A. Administering oxygen.
- B. Administering nitroglycerin.
- C. Administering aspirin.
- D. Administering morphine.
Correct answer: A
Rationale: Administering oxygen is the priority intervention for a patient with a suspected myocardial infarction to improve oxygenation. Oxygen helps ensure an adequate oxygen supply to the heart muscle, reducing the workload on the heart. Nitroglycerin and aspirin are important interventions in the treatment of MI; however, oxygen administration takes precedence to ensure adequate oxygenation. Morphine may be considered for pain relief, but it is not the initial priority in the treatment of a suspected MI.
3. A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. What action should the nurse implement?
- A. Determine if the client has also experienced breast tenderness and weight gain.
- B. Encourage the client to begin a regular, daily program of walking and exercise.
- C. Advise the client to notify the healthcare provider for immediate medical attention.
- D. Tell the client to stop taking the medication for a week to see if symptoms subside.
Correct answer: C
Rationale: Calf pain is indicative of thrombophlebitis, a serious, life-threatening complication associated with the use of oral contraceptives which requires further assessment and possibly immediate medical intervention.
4. A client presents with a urine specific gravity of 1.018. What action should the nurse take?
- A. Evaluate the client’s intake and output for the past 24 hours.
- B. Document the finding in the chart and continue to monitor.
- C. Obtain a specimen for a urine culture and sensitivity.
- D. Encourage the client to drink more fluids, especially water.
Correct answer: B
Rationale: A urine specific gravity of 1.018 falls within the normal range, indicating adequate hydration. Therefore, the appropriate action is to document this finding in the client's chart and continue monitoring. There is no need to evaluate intake and output, as the specific gravity is normal. Obtaining a urine culture and sensitivity or encouraging increased fluid intake is unnecessary in this situation.
5. In a patient with type 1 diabetes, which of the following is a sign of diabetic ketoacidosis (DKA)?
- A. Polyuria
- B. Bradycardia
- C. Dry skin
- D. Tachycardia
Correct answer: D
Rationale: Tachycardia is a sign of diabetic ketoacidosis (DKA) in a patient with type 1 diabetes. In DKA, the body responds to hyperglycemia and dehydration by increasing heart rate. Polyuria (increased urination) is a symptom of diabetes but not specific to DKA. Bradycardia (slow heart rate) and dry skin are not typical signs of DKA; instead, tachycardia and other signs of volume depletion are more common.
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