HESI RN
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1. The healthcare provider is unable to palpate the client's left pedal pulses. Which of the following actions should the healthcare provider take next?
- A. Auscultate the pulses with a stethoscope.
- B. Call the physician.
- C. Use a Doppler ultrasound device.
- D. Inspect the lower left extremity.
Correct answer: C
Rationale: When pedal pulses are not palpable, using a Doppler ultrasound device is the appropriate next step to locate the pulse. Auscultating the pulses with a stethoscope (Choice A) is used for assessing blood flow in arteries above the clavicle, not for pedal pulses. Calling the physician (Choice B) may be necessary at a later stage, but initially, using a Doppler ultrasound device to locate the pulse is more appropriate. Inspecting the lower left extremity (Choice D) can provide visual information but will not help in locating the pedal pulses, making it a less suitable option.
2. The healthcare provider provides dietary instructions about iron-rich food to a client with iron deficiency anemia. Which food selection made by the client indicates a need for additional instructions?
- A. Liver
- B. Kidney beans
- C. Oranges
- D. Leafy green vegetables
Correct answer: C
Rationale: Oranges are not a good source of iron, so selecting oranges indicates a need for additional instructions. Oranges are high in vitamin C, which can enhance iron absorption from other sources, but they are not rich in iron themselves. Liver, kidney beans, and leafy green vegetables are good sources of iron and would be beneficial for a client with iron deficiency anemia. Therefore, the correct answer is C.
3. What information will the nurse provide when counseling a patient starting a sulfonamide drug for a urinary tract infection?
- A. Drink several quarts of water daily.
- B. If stomach upset occurs, avoid taking antacids.
- C. Limit sun exposure to avoid skin reactions.
- D. Report any sore throat promptly.
Correct answer: A
Rationale: The correct answer is A: Drink several quarts of water daily. This advice aims to prevent crystalluria, a potential side effect of sulfonamide drugs. Option B is incorrect because antacids should not be taken with sulfonamides as they can decrease drug absorption. Option C is incorrect as sulfonamides can increase sensitivity to sunlight, not requiring sun exposure limitations but sun protection measures. Option D is incorrect because a sore throat could indicate a more serious adverse effect and should be promptly reported for evaluation.
4. A client diagnosed with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened, tenacious mucus, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurses to instruct the client about self-care?
- A. Call the clinic if undesirable side effects of medications occur
- B. Avoid crowded enclosed areas to reduce pathogen exposure
- C. Increase the daily intake of oral fluids to liquefy secretions
- D. Teach anxiety reduction methods for feelings of suffocation
Correct answer: C
Rationale: Increasing the daily intake of oral fluids is crucial for clients with asthma and bronchitis as it helps to liquefy thickened mucus, making it easier to clear the airways and manage symptoms. This self-care measure can improve the client's ability to breathe more effectively. Choice A is not the most immediate concern when addressing thickened mucus and breathing difficulties. While avoiding crowded areas is beneficial to prevent respiratory infections, it is not directly related to managing thickened secretions. Teaching anxiety reduction methods is important for overall well-being, but it does not directly address the physiological issue of thickened mucus in the airways.
5. A nurse contacts the healthcare provider after reviewing a client’s laboratory results and noting a blood urea nitrogen (BUN) of 35 mg/dL and a creatinine of 1.0 mg/dL. For which action should the nurse recommend a prescription?
- A. Intravenous fluids
- B. Hemodialysis
- C. Fluid restriction
- D. Urine culture and sensitivity
Correct answer: A
Rationale: The normal range for BUN is 10 to 20 mg/dL, and for creatinine, it is 0.6 to 1.2 mg/dL in males and 0.5 to 1.1 mg/dL in females. Creatinine is a more specific marker for kidney function compared to BUN. In this case, the client's creatinine level is within the normal range, indicating a non-renal cause for the elevated BUN. Dehydration is a common cause of increased BUN, so the appropriate action would be to recommend intravenous fluids to address the dehydration. Fluid restriction is not indicated as the client needs hydration. Hemodialysis is not appropriate for dehydration and is typically reserved for renal failure. The laboratory results do not suggest an infection, making a urine culture and sensitivity unnecessary in this scenario.
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