during the infusion of a second unit of packed red blood cells the clients temperature increases from 99 to 1016 f which intervention should the nurse
Logo

Nursing Elites

HESI RN

HESI RN Exit Exam 2023

1. During the infusion of a second unit of packed red blood cells, the client's temperature increases from 99 to 101.6 F. Which intervention should the nurse implement?

Correct answer: A

Rationale: An increase in temperature during a transfusion may indicate a transfusion reaction, which can be serious. Stopping the transfusion and starting a saline infusion is the priority action to prevent further complications and address the potential adverse reaction. Administering antipyretics (choice B) may mask the symptoms of a transfusion reaction, delaying appropriate treatment. While monitoring vital signs (choice C) is important, stopping the transfusion takes precedence to prevent harm. Notifying the healthcare provider (choice D) is essential but should not delay the immediate intervention of stopping the transfusion and starting a saline infusion.

2. A client with a history of myocardial infarction is admitted with chest pain. Which diagnostic test should the nurse anticipate preparing the client for first?

Correct answer: A

Rationale: The correct answer is A: Electrocardiogram (ECG). An electrocardiogram should be performed first to assess for cardiac ischemia in a client with a history of myocardial infarction and chest pain. This test provides immediate information about the heart's electrical activity. Choice B, Chest X-ray, is used to visualize the structures of the chest, including the heart and lungs, but it does not directly assess for cardiac ischemia. Choice C, Arterial blood gases (ABGs), measures the oxygen and carbon dioxide levels in the blood and assesses acid-base balance, which is not the primary concern in this scenario. Choice D, Echocardiogram, is an ultrasound of the heart that provides information about the heart's structure and function, but it is not the initial diagnostic test for assessing cardiac ischemia in this situation.

3. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which intervention is most important?

Correct answer: C

Rationale: Administering insulin is the most important intervention in managing diabetic ketoacidosis. In DKA, there is a lack of insulin leading to hyperglycemia and ketosis. Insulin administration helps to reduce blood glucose levels and correct metabolic acidosis, which are crucial in treating DKA. Administering intravenous fluids helps with dehydration, monitoring urine output is important to assess renal function, but the priority is addressing the underlying cause of DKA by administering insulin. Administering 50% dextrose IV push is incorrect as it would further elevate blood glucose levels, which is contraindicated in DKA.

4. An adult female client with chronic kidney disease (CKD) asks the nurse if she can continue taking her over-the-counter medications. Which medication poses the greatest threat to this client?

Correct answer: A

Rationale: The correct answer is A, Magnesium hydroxide (Maalox). In clients with chronic kidney disease (CKD), magnesium can accumulate to toxic levels as the kidneys are unable to excrete it efficiently. This can lead to hypermagnesemia, causing serious and potentially life-threatening complications. Birth control pills (choice B) are metabolized mainly by the liver and do not pose a significant threat to clients with CKD. Cough syrup containing codeine (choice C) should be used cautiously in CKD due to the risk of respiratory depression but does not pose as great a threat as magnesium accumulation. Cold medication containing alcohol (choice D) should be avoided in CKD but does not present the same level of danger as magnesium toxicity.

5. A client is admitted for type 2 diabetes mellitus (DM) and chronic kidney disease (CKD). Which breakfast selection by the client indicates effective learning?

Correct answer: B

Rationale: The correct answer is B. Oatmeal with butter, artificial sweetener, and strawberries is a suitable choice for a client with type 2 diabetes mellitus and chronic kidney disease as it provides a balanced meal that helps manage blood sugar levels and kidney function. Choice A contains high saturated fats and added sugars from bacon, butter, and jam, which are not ideal for this client. Choice C includes high sugar content from maple syrup and pancake, which can negatively impact blood sugar levels. Choice D contains high sugar content from orange juice and cold cereal, which can lead to blood sugar spikes, not suitable for a client with diabetes and CKD.

Similar Questions

A client with chronic kidney disease (CKD) is receiving erythropoietin therapy. Which laboratory value should the nurse monitor closely?
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which laboratory value should be monitored closely?
A client with a history of myocardial infarction is experiencing chest pain. Which intervention should the nurse implement first?
A client is admitted with a diagnosis of pneumonia and is receiving IV antibiotics. Which assessment finding indicates that the treatment is effective?
While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

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