a nurse evaluates a client with acute glomerulonephritis gn which manifestation should the nurse recognize as a positive response to the prescribed tr
Logo

Nursing Elites

HESI RN

HESI Medical Surgical Specialty Exam

1. A client with acute glomerulonephritis (GN) is being evaluated by a nurse. Which manifestation should the nurse recognize as a positive response to the prescribed treatment?

Correct answer: A

Rationale: A weight loss of 11 pounds in the past 10 days indicates fluid loss, a positive response to treatment for acute glomerulonephritis. It signifies that the glomeruli are functioning adequately to filter excess fluid. A urine specific gravity of 1.048 is high, indicating concentrated urine, which is not a positive response in this context. Blood in the urine is not a typical finding in glomerulonephritis, so its absence is expected and does not indicate a positive response to treatment. A blood pressure of 152/88 mm Hg is elevated and may suggest kidney damage or fluid overload, which are not positive responses to treatment.

2. The nurse is caring for a patient who is receiving oral potassium chloride supplements. The nurse notes that the patient has a heart rate of 120 beats per minute and has had a urine output of 200 mL in the past 12 hours. The patient reports abdominal cramping. Which action will the nurse take?

Correct answer: A

Rationale: Oliguria, tachycardia, and abdominal cramping are signs of hyperkalemia, so the nurse should request an order for serum electrolytes to assess the patient's potassium levels. Encouraging the patient to consume less fluids would not address the underlying issue of potential hyperkalemia. Reporting symptoms of hyperkalemia to the provider is not as proactive as directly requesting serum electrolytes. Increasing the patient's potassium dose would worsen hyperkalemia, which is already suspected based on the symptoms presented.

3. A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse should tell the client that:

Correct answer: C

Rationale: When an ELISA test for HIV is positive, it is essential to confirm the result with a Western blot. The Western blot is the confirmatory test for HIV. Choice A is incorrect because a positive ELISA test does not confirm HIV infection. Choice B is incorrect as it assumes a different diagnosis. Choice D is incorrect because a positive ELISA test does indicate potential HIV infection and requires confirmation.

4. What is the priority intervention for a patient with a suspected myocardial infarction (MI)?

Correct answer: A

Rationale: Administering oxygen is the priority intervention for a patient with a suspected myocardial infarction to improve oxygenation. Oxygen helps ensure an adequate oxygen supply to the heart muscle, reducing the workload on the heart. Nitroglycerin and aspirin are important interventions in the treatment of MI; however, oxygen administration takes precedence to ensure adequate oxygenation. Morphine may be considered for pain relief, but it is not the initial priority in the treatment of a suspected MI.

5. The provider has ordered Kayexalate and sorbitol to be administered to a patient. The nurse caring for this patient would expect which serum electrolyte values prior to administration of this therapy?

Correct answer: C

Rationale: Severe hyperkalemia, with a potassium level of 6.9 mEq/L, requires aggressive treatment with Kayexalate and sorbitol to increase the body’s excretion of potassium. The normal range for serum potassium is 3.5 to 5.5 mEq/L, so patients with the other potassium levels would not be treated aggressively or would need potassium supplementation. Therefore, option C (Sodium 135 mEq/L and potassium 6.9 mEq/L) is the correct choice as it indicates severe hyperkalemia warranting the administration of Kayexalate and sorbitol. Options A, B, and D have either potassium levels within normal limits, which would not necessitate this aggressive treatment, or potassium levels that are lower than what would typically prompt the need for Kayexalate and sorbitol.

Similar Questions

A client has a urine specific gravity of 1.040. What action should the nurse take?
A client who was involved in a motor vehicle collision is admitted with a fractured left femur that is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that the client's distal pulses are diminished in the left foot. Which intervention should the nurse implement?
Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?
The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury (AKI). Which condition would the nurse expect to find in the client’s recent history?
The nurse is teaching a nursing student about the minimal effective concentration (MEC) of antibiotics. Which statement by the nursing student indicates understanding of this concept?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses