HESI 799 RN Exit Exam

Correct Answer: C

Rationale: Obtaining an electrocardiogram (ECG) is the first priority in assessing for ischemia or infarction in a client with chest pain and a history of myocardial infarction. This diagnostic test provides crucial information about the heart's electrical activity and helps in identifying any acute cardiac changes. Administering oxygen therapy and nitroglycerin can be important interventions, but obtaining an ECG takes precedence as it directly assesses the client's cardiac status. Assessing the client's level of consciousness is also essential, but in this scenario, assessing for cardiac indications through an ECG is the initial step.

Correct Answer: A

Rationale: The correct action for the nurse to take next is to ask for a full explanation from the interpreter of the witnessed discussion. Verbal consent is not sufficient; it is crucial to ensure that the client fully comprehends the risks and benefits of the surgical procedure. By asking the interpreter to provide a detailed explanation of the discussion, the nurse can confirm that the client has given informed consent. Having the client sign the consent form (Choice B) without ensuring complete understanding may lead to potential misunderstandings. Documenting the conversation and witnessing the consent (Choice C) is not enough to guarantee the client's comprehension. Asking the client directly if she has any questions (Choice D) may not be effective if language barriers persist.

Correct Answer: A

Rationale: Administering 50% dextrose IV push is the first priority in treating hypoglycemia to rapidly increase blood glucose levels. This choice is correct because in severe cases of hypoglycemia, when a client is admitted and unconscious or unable to swallow, intravenous administration of dextrose is crucial to quickly raise blood glucose levels. Option B, administering 15 grams of oral glucose, would be suitable for conscious clients with mild hypoglycemia who can swallow safely. Option C, rechecking blood glucose levels, should follow after immediate intervention to assess the response. Option D, administering a glucagon injection, is more suitable for cases where dextrose is not readily available or when the client does not respond to dextrose administration.

Correct Answer: C

Rationale: Increasing humidity in the client's room is the initial intervention for managing thick, tenacious secretions in a client with a tracheostomy. Adequate humidity helps to hydrate secretions, making them easier to clear, thus improving airway clearance. Encouraging fluid intake (Choice A) can be beneficial but is not the first-line intervention. Administering a mucolytic agent (Choice B) may be considered if increasing humidity alone is insufficient. Performing deep suctioning (Choice D) should be reserved for when other measures like increasing humidity have been ineffective.

Correct Answer: D

Rationale: The vastus lateralis site is the most appropriate for an IM injection in a client with muscle wasting in the gluteal region. Administering the injection in the vastus lateralis ensures effective medication delivery due to muscle wasting in the gluteal region, preventing potential complications associated with the dorsogluteal or ventrogluteal sites, which may not be suitable in this specific client case. The deltoid site is mainly used for smaller volumes of medication and may not be ideal for this scenario.