RN HESI Exit Exam

Correct Answer: A

Rationale: The correct answer is A: Elevated blood pressure. In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, elevated blood pressure requires immediate intervention. This finding is concerning as it may indicate worsening hypertension, which can lead to further complications. Increased fatigue (choice B) is common in CKD but may not require immediate intervention unless severe. Headache (choice C) can be a symptom to monitor but does not pose an immediate threat like elevated blood pressure. Elevated hemoglobin (choice D) is actually a desired outcome of erythropoietin therapy and does not require immediate intervention.

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. High serum ammonia levels can lead to altered mental status, confusion, and even coma. Serum albumin (choice A) is often decreased in cirrhosis but does not require immediate intervention. Serum bilirubin (choice B) elevation is expected in cirrhosis and may not require immediate intervention unless very high. Serum sodium (choice D) within the given range is generally acceptable and does not require immediate intervention.

Correct Answer: B

Rationale: Administering insulin is the most important intervention in managing diabetic ketoacidosis. Insulin helps to reduce blood glucose levels and correct metabolic acidosis, which are critical in the treatment of DKA. While administering intravenous fluids is essential to manage dehydration, insulin takes precedence in treating the underlying cause of DKA. Monitoring urine output is important for assessing renal function but is not the primary intervention in managing DKA. Checking the client's blood glucose level is necessary, but administering insulin to reduce high blood glucose levels is the key priority in treating DKA.

Correct Answer: A

Rationale: Talking directly to the adolescent is the most appropriate intervention in this scenario. It helps maintain a sense of connection and respect, even if the response is not evident. Maintaining silence may lead to isolation and hinder any potential communication attempts. Playing soothing music may not provide the personal interaction needed for connection. Limiting visitors to immediate family only may deprive the patient of diverse interactions that could be beneficial for their emotional well-being.

Correct Answer: C

Rationale: When the PR interval is prolonged, it signifies an increased conduction time from the SA node through the AV junction. This finding is characteristic of a first-degree heart block where there is a delay in the electrical conduction at the level of the AV node. Choices A, B, and D are incorrect as they do not accurately reflect the significance of a prolonged PR interval.