RN HESI Exit Exam

Correct Answer: D

Rationale: The correct answer is to notify the healthcare provider. Purulent drainage at the incision site is concerning as it may indicate an infection. The healthcare provider needs to be informed promptly to initiate appropriate treatment. Applying a sterile dressing (Choice A) may not address the underlying issue of infection. Reinforcing the dressing and documenting findings (Choice B) is important but should be preceded by notifying the healthcare provider. Removing the dressing and assessing the incision site (Choice C) may disturb the area and should be done under the guidance of the healthcare provider.

Correct Answer: A

Rationale: The correct answer is A. Frequent use of magnesium-containing laxatives can lead to hypermagnesemia, particularly in elderly clients. Option B, dietary intake of magnesium-rich foods, may contribute to elevated serum magnesium levels but is less likely the cause in this scenario. Option C, the use of magnesium-containing supplements, can also contribute to hypermagnesemia but is not as common in elderly clients without a history of using such supplements. Option D, history of alcohol use, is less relevant to the development of elevated serum magnesium levels compared to laxative use for chronic constipation.

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: B

Rationale: Administering IV fluids as prescribed is the priority intervention in a client with a blood glucose level of 640 mg/dl and unresponsiveness. Severe hyperglycemia can lead to dehydration and electrolyte imbalances, and administering IV fluids can help manage hyperglycemia and prevent further complications. Administering dextrose IV push (Choice A) can exacerbate hyperglycemia in this scenario. Checking the client's blood glucose level (Choice C) is important but not the immediate priority when the client is unresponsive. Immediate dialysis (Choice D) is not indicated as the first intervention for hyperglycemia.

Correct Answer: A

Rationale: Adhering consistently to standards of care is crucial for nurses to reduce the risk of being named in a malpractice lawsuit. Following established protocols and guidelines ensures that the care provided is safe and effective. Thoroughly documenting all client interactions is also essential to support the care provided and to have a record of the interventions. Building a good rapport with clients is important for communication and trust but does not directly reduce the risk of malpractice. Working closely with the healthcare team is valuable for collaboration but might not directly impact the risk of malpractice unless it relates to following standards of care.