HESI RN
HESI RN Exit Exam 2024 Quizlet
1. Which assessment finding requires immediate intervention for a client receiving enteral feedings via a nasogastric tube?
- A. Auscultate the client's lungs for breath sounds
- B. Check the client's blood glucose level
- C. Monitor the client's bowel sounds
- D. Elevate the head of the bed to 45 degrees
Correct answer: D
Rationale: Elevating the head of the bed to 45 degrees is crucial for clients receiving enteral feedings via a nasogastric tube to prevent aspiration. Aspiration can lead to serious complications such as pneumonia. Auscultating the client's lungs for breath sounds (choice A) is important but not as urgent as preventing aspiration. Checking the client's blood glucose level (choice B) and monitoring bowel sounds (choice C) are also essential aspects of care for a client receiving enteral feedings, but they do not take precedence over preventing aspiration.
2. A client with type 2 diabetes mellitus is prescribed metformin. The nurse should monitor the client for which of the following potential side effects?
- A. Lactic acidosis
- B. Hypokalemia
- C. Hyperglycemia
- D. Weight gain
Correct answer: A
Rationale: The correct answer is A, lactic acidosis. Metformin, a common medication for type 2 diabetes mellitus, can lead to lactic acidosis, particularly in individuals with renal impairment or predisposing factors. Monitoring for signs of lactic acidosis, such as muscle pain, weakness, trouble breathing, dizziness, and slow or uneven heart rate, is crucial to prevent serious complications. Choices B, C, and D are incorrect as metformin does not typically cause hypokalemia, hyperglycemia, or weight gain as its primary side effects.
3. A client is admitted with a diagnosis of right-sided heart failure. What assessment finding should the nurse anticipate?
- A. Jugular vein distention.
- B. Crackles in the lungs.
- C. Peripheral edema.
- D. Hepatomegaly.
Correct answer: C
Rationale: In right-sided heart failure, the heart's inability to effectively pump blood to the lungs leads to fluid backup in the systemic circulation, resulting in peripheral edema (swelling in lower extremities). While jugular vein distention (A) and hepatomegaly (D) can also occur in right-sided heart failure, peripheral edema is a hallmark sign due to fluid retention. Crackles in the lungs (B) are more commonly associated with left-sided heart failure, where fluid accumulates in the lungs.
4. A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respirations. The nurse determines that the increased respiratory rate is a compensatory mechanism for which acid-base alteration?
- A. Metabolic alkalosis.
- B. Respiratory acidosis.
- C. Respiratory alkalosis.
- D. Metabolic acidosis.
Correct answer: D
Rationale: Kussmaul respirations are deep, rapid breathing patterns observed in metabolic acidosis, such as diabetic ketoacidosis. In this condition, the body tries to compensate for the acidic environment by increasing the respiratory rate to eliminate excess carbon dioxide (CO2) and decrease the acid levels, thereby helping to correct the acid-base imbalance. Therefore, the correct answer is metabolic acidosis.
5. A female client with breast cancer who completed her first chemotherapy treatment today at an outpatient center is preparing for discharge. Which behavior indicates that the client understands her care needs?
- A. Rented movies and borrowed books to use while passing time at home
- B. Made an appointment with the oncologist for follow-up treatment
- C. Expressed concern about hair loss and fatigue
- D. Asked for dietary recommendations to manage nausea
Correct answer: A
Rationale: Choice A is the correct answer. Renting movies and borrowing books to use at home indicate that the client understands the need for rest and self-care after chemotherapy. This behavior demonstrates the client's intention to engage in activities that promote relaxation and recovery. Choices B, C, and D are incorrect because making an appointment for follow-up treatment, expressing concern about side effects like hair loss and fatigue, and asking for dietary recommendations are important but do not directly reflect the client's understanding of her immediate care needs post-chemotherapy.