HESI RN
HESI 799 RN Exit Exam Quizlet
1. When obtaining a rectal temperature with an electronic thermometer, which action is most important for the nurse to perform?
- A. Hold the thermometer in place.
- B. Place the disposable pad under the buttocks.
- C. Instruct the client to breathe deeply.
- D. Return the probe to the charger.
Correct answer: A
Rationale: When obtaining a rectal temperature with an electronic thermometer, holding the thermometer in place is crucial. This action ensures accurate temperature measurement and prevents injury to the client. Option B, placing a disposable pad under the buttocks, is not the most important action; it may enhance comfort but does not impact the accuracy of the temperature reading. Option C, instructing the client to breathe deeply, is irrelevant to obtaining a rectal temperature. Option D, returning the probe to the charger, is an incorrect action after temperature measurement.
2. A molecule's specific heat is the amount of heat necessary to raise the temperature of 1 gram of that molecule by:
- A. One degree Celsius
- B. Five degrees Celsius
- C. Two degrees Celsius
- D. Four degrees Celsius
Correct answer: A
Rationale: The correct answer is A: 'One degree Celsius.' Specific heat is defined as the amount of heat required to raise the temperature of one gram of a substance by one degree Celsius. This property is specific to each substance and is used in various calculations involving heat and temperature changes. Choices B, C, and D are incorrect because specific heat is always measured per one degree Celsius increase in temperature for one gram of the substance, not five degrees, two degrees, or four degrees.
3. A client with adrenal insufficiency is admitted to the ICU with acute adrenal crisis. The client's vital signs include heart rate 138 bpm and BP 80/60. What is the nurse's first intervention?
- A. Obtain an analgesic prescription.
- B. Administer an IV fluid bolus.
- C. Administer PRN antipyretic.
- D. Cover the client with a cooling blanket.
Correct answer: B
Rationale: The correct first intervention for a client with adrenal crisis and hypotension is to administer an IV fluid bolus. In adrenal crisis, the body is deficient in cortisol, leading to hypotension. Fluid resuscitation helps stabilize the blood pressure. Obtaining an analgesic prescription (Choice A) is not the priority in this situation. Administering a PRN antipyretic (Choice C) is not indicated as the client's vital signs do not suggest fever. Covering the client with a cooling blanket (Choice D) is not appropriate for addressing hypotension in adrenal crisis.
4. A client with tuberculosis is prescribed rifampin. What side effect should the nurse inform the client about?
- A. Report orange-colored urine as a sign of kidney dysfunction.
- B. Expect red-orange discoloration of urine as a harmless side effect.
- C. Monitor for signs of liver toxicity.
- D. Call the healthcare provider if vision changes occur.
Correct answer: B
Rationale: The correct answer is B. Rifampin can cause red-orange discoloration of bodily fluids, including urine, saliva, and tears. This is a harmless side effect, but clients should be informed beforehand to prevent alarm. Choice A is incorrect as orange-colored urine is not a sign of kidney dysfunction related to rifampin. Choice C is incorrect because rifampin is more commonly associated with liver toxicity rather than kidney dysfunction. Choice D is incorrect as vision changes are not a typical side effect of rifampin.
5. Which of the following is a priority nursing diagnosis for a client with Addison's disease?
- A. Fluid volume deficit
- B. Risk for infection
- C. Imbalanced nutrition: Less than body requirements
- D. Disturbed body image
Correct answer: A
Rationale: The priority nursing diagnosis for a client with Addison's disease is 'Fluid volume deficit.' Addison's disease is characterized by adrenal insufficiency, resulting in decreased aldosterone production. Aldosterone plays a key role in sodium and water retention in the body. With its deficiency, there is an increased risk of dehydration and electrolyte imbalance, leading to fluid volume deficit. While infection risk, nutrition issues, and body image disturbances are also important considerations for holistic care, addressing the fluid volume deficit takes precedence due to the immediate physiological impact on the client's health and well-being.