HESI RN Exit Exam 2024 Quizlet

Questions 69

HESI RN

HESI RN Test Bank

HESI RN Exit Exam 2024 Quizlet Questions

Question 1 of 5

A client with cirrhosis is admitted with jaundice and ascites. Which intervention should the nurse implement first?

Correct Answer: B

Rationale: Administering lactulose is the first priority in managing a client with cirrhosis to reduce ammonia levels and prevent worsening hepatic encephalopathy. Lactulose helps in decreasing the absorption of ammonia in the intestines and promotes its excretion through the stool. This intervention is crucial in preventing the development or progression of hepatic encephalopathy. Administering a diuretic (Choice A) may be necessary to manage ascites, but it is not the priority over lactulose in this scenario. Monitoring the client's weight (Choice C) is important to assess fluid retention but is not the first intervention required. Assessing the client's neurological status (Choice D) is essential in cirrhosis, but administering lactulose takes precedence to prevent hepatic encephalopathy.

Question 2 of 5

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which assessment finding requires immediate intervention?

Correct Answer: C

Rationale: The correct answer is C: Use of accessory muscles. In a client with COPD and pneumonia, the use of accessory muscles indicates increased work of breathing and may signal respiratory failure. Immediate intervention is necessary to prevent further deterioration of the respiratory status. Choice A, an oxygen saturation of 90%, though low, may not require immediate intervention as it is above the typical threshold for initiating supplemental oxygen. Choice B, a respiratory rate of 24 breaths per minute, falls within the normal range for an adult and may not be an immediate cause for concern. Choice D, inspiratory crackles, are indicative of fluid in the lungs but may not require immediate intervention unless accompanied by other concerning signs like decreased oxygen saturation or increased respiratory distress.

Question 3 of 5

A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a 'Do Not Resuscitate' prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. What action should the nurse take?

Correct Answer: A

Rationale: Continuing to turn the client is crucial to prevent complications such as pressure ulcers, even if the client is less responsive. Advising the UAP to resume positioning the client on schedule is the most appropriate action in this situation. This action ensures that the client's care needs are met and helps prevent potential complications. Notifying the healthcare provider or documenting the UAP's actions may delay the necessary care for the client. Discussing the situation with the client's family is important but addressing the immediate care need of turning the client takes priority.

Question 4 of 5

A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which clinical finding is most concerning?

Correct Answer: D

Rationale: A serum bicarbonate level of 18 mEq/L is most concerning in a client with DKA as it indicates metabolic acidosis, requiring immediate intervention. In DKA, the body produces excess ketones, leading to metabolic acidosis. A low serum bicarbonate level is a key indicator of this acid-base imbalance. Elevated serum glucose levels are expected in DKA but are managed through insulin therapy. Serum potassium levels can fluctuate in DKA due to insulin deficiency, but a value of 5.5 mEq/L is not as immediately concerning as metabolic acidosis. Therefore, the most critical finding in this scenario is the low serum bicarbonate level.

Question 5 of 5

The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should the nurse monitor closely?

Correct Answer: A

Rationale: In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, the nurse should closely monitor the serum potassium level. Erythropoietin therapy can increase red blood cell production, leading to a higher demand for potassium. Monitoring potassium levels is crucial to prevent hyperkalemia, a potential risk associated with this therapy. Hemoglobin level (Choice B) is important to assess the effectiveness of erythropoietin therapy, but monitoring potassium levels takes precedence due to the risk of hyperkalemia. White blood cell count (Choice C) and serum calcium level (Choice D) are not directly affected by erythropoietin therapy in the context of chronic kidney disease.

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