HESI RN
HESI RN Exit Exam 2024 Quizlet Capstone
1. What is the primary purpose of the logrolling technique for turning?
- A. To decrease the risk of back injury by working together.
- B. To maintain straight spinal alignment.
- C. To increase client safety by using two or three people.
- D. To reduce the likelihood of skin damage by turning instead of pulling.
Correct answer: B
Rationale: The correct answer is B: To maintain straight spinal alignment. Logrolling is a technique used to carefully turn a client while keeping the spine in a straight line, especially important for those with spinal injuries or after back surgery. Choice A is incorrect because the primary purpose is not specifically to decrease the risk of back injury but to ensure safe turning. Choice C is incorrect as the main aim is not to increase client safety by using multiple people but to protect the spine. Choice D is incorrect because the primary purpose of logrolling is not to prevent skin damage but to safeguard the spine during turning.
2. A client with hypoglycemia is unresponsive. What is the nurse's priority action?
- A. Administer intravenous dextrose.
- B. Check the client's blood glucose level.
- C. Administer glucagon intramuscularly.
- D. Prepare to administer oral glucose.
Correct answer: C
Rationale: The correct answer is to administer glucagon intramuscularly. In an unresponsive hypoglycemic client, administering glucagon intramuscularly is the priority action as it helps raise blood glucose levels quickly. Intravenous dextrose may be challenging to administer in an unresponsive client. Checking the client's blood glucose level is important but not the priority when the client is unresponsive. Preparing to administer oral glucose is not ideal for an unresponsive client as they may not be able to swallow.
3. What is the most important information for a nurse to obtain when an older female client expresses not deserving to eat due to lack of money?
- A. Client's thoughts about wanting to hurt herself
- B. Medication history for antipsychotic agents
- C. Availability of family members to provide meals
- D. Community resources to provide financial aid
Correct answer: A
Rationale: The correct answer is A: Client's thoughts about wanting to hurt herself. When a client expresses not deserving to eat due to lack of money, it raises concerns about her mental and emotional well-being. Assessing for suicidal ideation is crucial in this situation to ensure the client's immediate safety. Options B, C, and D are not the most critical information to obtain in this scenario. While medication history, family support, and community resources are important aspects of care, in this context, the client's mental health and risk of self-harm take precedence.
4. A client with a history of bipolar disorder is exhibiting symptoms of mania. Which intervention is most appropriate for the nurse to implement?
- A. Encourage the client to participate in group therapy.
- B. Provide a calm and structured environment.
- C. Limit stimulation and set firm limits on behavior.
- D. Promote self-care and hygiene practices.
Correct answer: C
Rationale: When a client with bipolar disorder is experiencing symptoms of mania, the most appropriate intervention for the nurse is to limit stimulation and set firm limits on behavior. This approach helps in managing the manic episode by preventing further escalation. Encouraging participation in group therapy (Choice A) may not be effective during the acute phase of mania, as the client may have difficulty focusing or following group discussions. Providing a calm and structured environment (Choice B) is beneficial, but setting firm limits is crucial to managing the impulsivity and risky behaviors associated with mania. Promoting self-care practices (Choice D) is important, but during a manic episode, setting limits and reducing stimuli take precedence over hygiene practices.
5. A 14-year-old girl with asthma complains of feeling nervous and jittery after a respiratory therapy bronchodilator treatment. What explanation is best for the nurse to provide to this adolescent?
- A. Nervousness should disappear when hypoxia is relieved after several bronchodilator treatments
- B. Tremors result from the rapid dilation of the bronchioles and an increased heart rate
- C. A fast heart rate and jitteriness are side effects of the bronchodilator treatment containing albuterol
- D. Excessive coughing, which causes tachypnea and anxiety, result from the use of bronchodilators
Correct answer: C
Rationale: The correct answer is C because a fast heart rate and jitteriness are common side effects of bronchodilators like albuterol. Choice A is incorrect as nervousness is more likely a side effect of the medication than solely related to hypoxia. Choice B is incorrect as it provides a partial explanation focusing only on tremors and heart rate, not mentioning jitteriness. Choice D is incorrect because excessive coughing and tachypnea are not typically associated with bronchodilator use; instead, they may indicate inadequate relief or other issues.