when evaluating the effectiveness of a clients nursing care the nurse first reviews the expected outcomes identified in the plan of care what action s
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Nursing Elites

HESI RN

HESI Fundamentals Practice Test

1. When evaluating the effectiveness of a client’s nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

Correct answer: A

Rationale: After reviewing the expected outcomes identified in the plan of care, the nurse's next step should be to determine if these outcomes were realistic. This assessment helps in understanding if the goals set were achievable and appropriate for the client's condition before proceeding to compare them with current client data or modifying nursing interventions. By verifying the realism of the expected outcomes, the nurse ensures a solid foundation for further evaluation and adjustment of the care plan. Option B is incorrect because obtaining current client data comes after assessing the realism of the expected outcomes. Option C is incorrect because modifying nursing interventions should be based on the assessment of the expected outcomes' realism. Option D is incorrect as reviewing professional standards of care is important but not the immediate next step after assessing the expected outcomes' realism.

2. A client is admitted with a diagnosis of acute pancreatitis. Which assessment finding is most indicative of this diagnosis?

Correct answer: A

Rationale: Epigastric pain that radiates to the back (A) is the hallmark assessment finding of acute pancreatitis. The pancreas lies retroperitoneally in the upper abdomen, so inflammation often causes severe epigastric pain that radiates through to the back. While abdominal pain with guarding (B), nausea and vomiting (C), and increased bowel sounds (D) can also be present in acute pancreatitis, they are less specific and may be seen in various other gastrointestinal conditions. Therefore, the most indicative finding for acute pancreatitis is epigastric pain that radiates to the back.

3. A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump?

Correct answer: B

Rationale: The correct calculation involves dividing the total volume by the total time. In this case, 250 ml/4 hours = 63 ml/hour. The dose of KCl is not used in the calculation as the focus is on the rate of infusion over the specified time period. Choice A (13 ml/hour) is incorrect as it does not result from the correct calculation. Choice C (80 ml/hour) and Choice D (125 ml/hour) are also incorrect calculations and do not match the correct rate of infusion required.

4. The client has a chest tube. What is the most important action for the nurse to take?

Correct answer: C

Rationale: Keeping the drainage system below the level of the chest (C) is crucial to ensure proper drainage and prevent backflow of air or fluid into the chest cavity. This position helps maintain the integrity of the closed drainage system. Ensuring the chest tube remains unclamped at all times (A) allows for continuous drainage. Emptying the chest tube (B) should be done as needed, not routinely every 2 hours. Assessing for subcutaneous emphysema (D) is important but not the most critical action in this scenario.

5. A client with chronic renal failure is receiving epoetin alfa (Epogen). Which laboratory test should the nurse monitor to evaluate the effectiveness of this medication?

Correct answer: B

Rationale: The correct answer is B: Hemoglobin and hematocrit. These are the primary laboratory tests to monitor the effectiveness of epoetin alfa (Epogen) in treating anemia. White blood cell count (A), platelet count (C), and blood urea nitrogen (BUN) and creatinine (D) are not directly related to the effects of this medication. Epoetin alfa stimulates the production of red blood cells, so monitoring hemoglobin and hematocrit levels helps assess the response to the treatment.

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