HESI RN
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1. The nurse is caring for a client with chronic renal failure who is on a low-potassium diet. Which of the following foods should the client avoid?
- A. Bananas
- B. Potatoes
- C. Rice
- D. Apples
Correct answer: A
Rationale: Bananas are high in potassium content, which can lead to hyperkalemia in clients with chronic renal failure who are on a low-potassium diet. Therefore, it is crucial for these clients to avoid bananas. Potatoes, rice, and apples are lower in potassium compared to bananas and are generally considered safe for consumption in clients with chronic renal failure on a low-potassium diet.
2. An overweight client taking warfarin (Coumadin) has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply.
- A. Apply lanolin or petroleum jelly to intact skin.
- B. Follow a reduced-calorie, reduced-fat diet.
- C. Inspect the involved areas daily for new ulcerations.
- D. Instruct the client to limit activities of daily living (ADLs).
Correct answer: A
Rationale: To address dry skin and prevent chronic ulcers and infections in an overweight client on warfarin with decreased arterial blood flow, the nurse should instruct the client to apply lanolin or petroleum jelly to intact skin. This helps maintain skin integrity and moisture. Following a reduced-calorie, reduced-fat diet (Choice B) may be beneficial for weight management but is not directly related to skin care. Inspecting involved areas daily for new ulcerations (Choice C) is important for skin assessment and early intervention but does not specifically address dry skin. Instructing the client to limit activities of daily living (ADLs) (Choice D) is not necessary for addressing dry skin; in fact, promoting mobility and circulation through appropriate activities is crucial.
3. After the administration of t-PA, what should the nurse do?
- A. Observe the client for chest pain.
- B. Monitor for fever.
- C. Review the 12-lead electrocardiogram (ECG).
- D. Auscultate breath sounds.
Correct answer: A
Rationale: After the administration of t-PA, the nurse should observe the client for chest pain. Chest pain post t-PA administration could indicate reocclusion of the coronary artery, a serious complication that requires immediate intervention. Monitoring for fever (choice B) is not specifically associated with t-PA administration. While reviewing the 12-lead ECG (choice C) is important for assessing cardiac function, it may not be the immediate priority right after t-PA administration. Auscultating breath sounds (choice D) is important for assessing respiratory status but is not the most crucial assessment following t-PA administration.
4. Which of the following medications is typically used to treat asthma?
- A. Aspirin
- B. Metformin
- C. Albuterol
- D. Lisinopril
Correct answer: C
Rationale: The correct answer is C, Albuterol. Albuterol is a bronchodilator commonly used to treat asthma by relaxing the muscles around the airways, helping to relieve symptoms such as coughing, wheezing, shortness of breath, and chest tightness. Aspirin (Choice A) is not typically used to treat asthma and can actually trigger asthma symptoms in some individuals. Metformin (Choice B) is a medication for managing type 2 diabetes and is not indicated for asthma treatment. Lisinopril (Choice D) is an angiotensin-converting enzyme (ACE) inhibitor primarily used to treat high blood pressure and heart failure, not asthma.
5. The healthcare provider prescribes diagnostic tests for a client with pneumonia identified on a chest X-ray. Which diagnostic test should the nurse review for implementation to guide the most therapeutic treatment of pneumonia?
- A. Sputum culture and sensitivity
- B. Blood cultures
- C. Arterial blood gases (ABG)
- D. Computerized tomography (CT) of the chest
Correct answer: A
Rationale: Sputum culture and sensitivity is the most appropriate diagnostic test for pneumonia as it helps in identifying the causative organism, which is crucial for guiding the selection of the most effective antibiotic therapy. Blood cultures (choice B) are more useful in identifying systemic infections rather than pneumonia specifically. Arterial blood gases (ABG) (choice C) are helpful in assessing oxygenation but do not directly aid in identifying the causative organism. Computerized tomography (CT) of the chest (choice D) is useful for evaluating structural abnormalities in the lungs but is not the initial test of choice for diagnosing pneumonia.
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