HESI RN
HESI RN Exit Exam 2024 Quizlet
1. A client with chronic kidney disease (CKD) is admitted with hyperkalemia. Which laboratory value is most concerning?
- A. Serum potassium of 6.5 mEq/L
- B. Serum sodium of 135 mEq/L
- C. Serum creatinine of 2.0 mg/dl
- D. Blood glucose of 150 mg/dl
Correct answer: A
Rationale: A serum potassium level of 6.5 mEq/L is concerning in a client with CKD as it indicates hyperkalemia, which requires immediate intervention to prevent cardiac complications. Hyperkalemia can lead to life-threatening arrhythmias, particularly in patients with impaired kidney function. Serum sodium, creatinine, and blood glucose levels, while important, are not as acutely dangerous as severe hyperkalemia in this context.
2. A client who is post-op day 1 after abdominal surgery reports pain at the incision site. The nurse notes the presence of a small amount of serosanguineous drainage. What is the most appropriate nursing action?
- A. Apply a sterile dressing to the incision.
- B. Reinforce the dressing and document the findings.
- C. Remove the dressing and assess the incision site.
- D. Notify the healthcare provider.
Correct answer: B
Rationale: The correct answer is to reinforce the dressing and document the findings. It is important to monitor the incision site closely after surgery, especially when there is a small amount of serosanguineous drainage. Reinforcing the dressing helps maintain cleanliness and pressure on the wound. Documenting the findings is crucial for tracking the client's progress and alerting healthcare providers if necessary. Applying a sterile dressing (Choice A) may not be needed if the current dressing is intact. Removing the dressing (Choice C) can increase the risk of contamination. Notifying the healthcare provider (Choice D) is not the first step for minor drainage on post-op day 1.
3. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which clinical finding requires immediate intervention?
- A. Serum glucose of 300 mg/dL
- B. Serum potassium of 5.5 mEq/L
- C. Serum bicarbonate of 18 mEq/L
- D. Positive urine ketones
Correct answer: C
Rationale: A serum bicarbonate level of 18 mEq/L indicates metabolic acidosis in a client with DKA, requiring immediate intervention. In DKA, the body produces excess ketones, leading to metabolic acidosis, which is reflected by a low serum bicarbonate level. Correcting the low serum bicarbonate is crucial to normalize the metabolic acidosis and improve the client's condition. While elevated serum glucose (choice A) and urine ketones (choice D) are characteristic of DKA, addressing the metabolic acidosis takes precedence. Serum potassium (choice B) levels may also need monitoring and management, but correcting the acidosis is the priority to prevent complications like cardiovascular collapse.
4. The nurse is assessing a client with chronic heart failure who is receiving furosemide (Lasix). Which assessment finding is most concerning?
- A. Heart rate of 60 beats per minute
- B. Blood pressure of 110/70 mmHg
- C. Elevated liver enzymes
- D. Elevated blood glucose level
Correct answer: C
Rationale: Elevated liver enzymes are most concerning in a client with chronic heart failure as they may indicate liver congestion or worsening heart failure, requiring immediate intervention. Elevated liver enzymes can be a sign of hepatotoxicity or liver damage, which could be a result of furosemide (Lasix) use. Monitoring liver function is crucial in patients taking furosemide due to the risk of hepatotoxicity. A heart rate of 60 beats per minute and a blood pressure of 110/70 mmHg are within normal ranges for a client with chronic heart failure. An elevated blood glucose level may be expected due to the effects of furosemide but is not as immediately concerning as elevated liver enzymes.
5. The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete?
- A. Auscultate the client's bowel sounds
- B. Observe for edema around the ankles
- C. Measure the client's capillary glucose level
- D. Count the apical and radial pulses simultaneously
Correct answer: A
Rationale: The correct answer is to auscultate the client's bowel sounds. Hydromorphone is a potent opioid analgesic that can slow peristalsis and commonly cause constipation. By assessing the client's bowel sounds, the nurse can monitor for any signs of decreased bowel motility or potential constipation. Observing for edema (Choice B) is not directly related to hydromorphone administration. Measuring capillary glucose levels (Choice C) is not the priority in this situation. Counting the apical and radial pulses simultaneously (Choice D) is not specifically indicated in this scenario involving hydromorphone administration.
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