HESI 799 RN Exit Exam

Questions 72

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HESI 799 RN Exit Exam Questions

Question 1 of 5

A client is admitted with a possible myocardial infarction. Which laboratory test result is most indicative of a myocardial infarction?

Correct Answer: B

Rationale: Serum troponin is the most specific and sensitive indicator of myocardial infarction. Troponin levels rise within 3-4 hours after myocardial damage, peak at 10-24 hours, and remain elevated for up to 10-14 days. Creatine kinase (CK) and myoglobin can also be elevated in myocardial infarction, but troponin is more specific to cardiac muscle damage. C-reactive protein (CRP) is a marker of inflammation and is not specific for myocardial infarction.

Question 2 of 5

Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which action should the nurse implement?

Correct Answer: A

Rationale: After an open reduction of the tibia, bleeding on the cast can be a concern. Outlining the area with ink and monitoring it every 15 minutes is the appropriate action to assess if the bleeding is worsening, indicating the need for further intervention. This action allows for close observation without disturbing the cast. Choice B is incorrect because while notifying the healthcare provider is important, immediate action is not always necessary if the bleeding is not severe. Choice C is incorrect because applying a new cast is not the standard intervention for bleeding on a cast. Choice D is incorrect because elevating the limb may not address the underlying cause of bleeding and may not be the most appropriate action at this time.

Question 3 of 5

In a client with cirrhosis admitted with jaundice and ascites, which laboratory value is most concerning?

Correct Answer: C

Rationale: A serum ammonia level of 80 mcg/dl is most concerning in a client with cirrhosis as it may indicate hepatic encephalopathy, requiring immediate intervention. Elevated ammonia levels are associated with impaired liver function and can lead to mental status changes. Serum bilirubin (Choice A) is elevated in cirrhosis but not as concerning for acute intervention as high ammonia levels. Serum albumin (Choice B) and serum sodium (Choice D) levels are important in cirrhotic patients but are not as directly associated with hepatic encephalopathy as ammonia levels.

Question 4 of 5

A nurse plans to call the healthcare provider to report an 0600 serum potassium level of 2 mEq/L or mmol/L (SI), but the charge nurse tells the nurse that the healthcare provider does not like to receive early morning calls and will make rounds later in the morning. What action should the nurse take?

Correct Answer: A

Rationale: A nurse should contact the healthcare provider immediately to report a critically low potassium level of 2 mEq/L. Potassium levels below the normal range can lead to life-threatening complications such as cardiac arrhythmias. Prompt notification is essential to ensure timely intervention and prevent harm to the patient. Option B is incorrect as delaying reporting such a critical value can jeopardize patient safety. Option C is not the priority in this situation; the focus should be on patient care. Option D is dangerous and inappropriate as administering a potassium supplement without healthcare provider's guidance can be harmful, especially with a critically low level.

Question 5 of 5

A client who recently underwent a tracheostomy is being prepared for discharge to home. Which instruction is most important for the nurse to include in the discharge plan?

Correct Answer: B

Rationale: The most important instruction for a client who recently underwent a tracheostomy is to teach tracheal suctioning techniques. Suctioning helps clear secretions and maintain an open airway, which is critical for the client's respiratory function and overall well-being. While communication tools, self-care, and cleaning the tracheostomy site are important aspects of care, ensuring proper suctioning techniques is crucial for preventing complications and ensuring the client's safety.

Similar Questions

A client who recently underwent a tracheostomy is being prepared for discharge to home. Which instruction is most important for the nurse to include in the discharge plan?
A male client with impaired renal function who takes ibuprofen daily for chronic arthritis is admitted with gastrointestinal (GI) bleeding. After administering IV fluids and a blood transfusion, his blood pressure is 100/70, and his renal output is 20 ml/hour. Which intervention should the nurse include in care?
The nurse is preparing to administer an IV dose of ciprofloxacin to a client with a urinary tract infection. Which client data requires the most immediate intervention by the nurse?
The nurse is assessing a female client's blood pressure because she reported feeling dizzy. The blood pressure cuff is inflated to 140 mm Hg and as soon as the cuff is deflated a Korotkoff sound is heard. Which intervention should the nurse implement next?
A client with a history of congestive heart failure is admitted with shortness of breath. Which nursing intervention should the nurse implement first?

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