HESI 799 RN Exit Exam

Correct Answer: B

Rationale: The correct intervention in this situation is to infuse a rapid IV normal saline bolus. The client's drop in blood pressure to 60/40 mm Hg after nitroglycerin administration indicates hypotension, which may suggest a right ventricular infarction. Normal saline bolus helps to increase intravascular volume, improve cardiac output, and support blood pressure. Administering a second dose of nitroglycerin would further decrease blood pressure. External chest compressions are not indicated as the client's heart is still beating, and there is no indication for CPR. Giving an antiemetic medication is not the priority in this situation where hypotension is the main concern.

Correct Answer: A

Rationale: The correct answer is A: 'Expresses an understanding of the procedure.' This choice indicates that the client is mentally prepared for the pulmonary function tests, as understanding the procedure shows readiness and cooperation. Choices B, C, and D are incorrect. Choice B, 'NPO for 6 hrs,' pertains to fasting status and is not directly related to readiness for the test. Choice C, 'No known drug allergies,' is important information but does not specifically indicate readiness for pulmonary function tests. Choice D, 'Intravenous access intact,' is related to vascular access and not a direct indicator of readiness for the pulmonary function tests.

Correct Answer: C

Rationale: The correct answer is C: Potassium of 6.0 mEq/L. A potassium level of 6.0 mEq/L is dangerously high in a client with CKD, and it should be reported before hemodialysis to prevent cardiac complications. High potassium levels can lead to life-threatening arrhythmias. Choices A, B, and D are not the most critical values to report before hemodialysis. While a serum potassium level of 5.5 mEq/L is slightly elevated, it is not as urgent as a level of 6.0 mEq/L in this context. Hemoglobin of 10 g/dl and blood glucose of 200 mg/dl are important parameters to monitor but are not as immediately concerning before hemodialysis compared to a high potassium level.

Correct Answer: A

Rationale: If a Korotkoff sound is heard immediately upon deflation, it may indicate an inaccurate reading. Waiting and palpating the systolic pressure can help confirm the accuracy of the measurement. Choice A is the correct intervention because it allows the nurse to ensure the accuracy of the blood pressure reading. Choice B is incorrect as increasing the inflation pressure is not necessary in this situation. Choice C is also incorrect as switching to a larger cuff is not warranted based on the information provided. Choice D is incorrect because documenting the finding as normal without further verification could lead to inaccurate information.

Correct Answer: C

Rationale: An ammonia level of 80 mcg/dL is elevated and concerning in a client with liver cirrhosis, as it may indicate hepatic encephalopathy. Elevated ammonia levels can lead to cognitive impairment, altered mental status, and even coma. Serum albumin, bilirubin, and prothrombin time are also important markers in liver cirrhosis but are not as directly associated with the risk of hepatic encephalopathy as elevated ammonia levels.