HESI RN
HESI 799 RN Exit Exam
1. In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse (PN)?
- A. An older client who fell yesterday and is now complaining of diplopia.
- B. An adult newly diagnosed with type 1 diabetes and high cholesterol.
- C. A client with pancreatic cancer who is experiencing intractable pain.
- D. An older client post-stroke who is aphasic with right-sided hemiplegia.
Correct answer: D
Rationale: The best client for the charge nurse to assign to a practical nurse (PN) is an older client post-stroke who is aphasic with right-sided hemiplegia. This client is stable and suitable for care by a PN under supervision. Choices A, B, and C present clients with more complex and acute conditions that would require a higher level of nursing expertise and intervention.
2. A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?
- A. Palpitations and shortness of breath
- B. Bradycardia and constipation
- C. Lethargy and lack of appetite
- D. Muscle cramping and dry, flushed skin
Correct answer: A
Rationale: The correct answer is A. An overdose of thyroid preparation generally manifests symptoms of an agitated state such as tremors, palpitations, shortness of breath, tachycardia, increased appetite, agitation, sweating, and diarrhea. Palpitations and shortness of breath are signs of excessive thyroid medication. Choices B, C, and D are incorrect symptoms for a dosage that is too high. Bradycardia and constipation, lethargy and lack of appetite, muscle cramping and dry, flushed skin are more indicative of hypothyroidism or an insufficient dosage of levothyroxine.
3. After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement?
- A. Send stool specimen to the lab
- B. Measure abdominal girth
- C. Encourage increased fiber in the diet
- D. Monitor mental status
Correct answer: D
Rationale: The correct action for the nurse to implement after a client with hepatic encephalopathy has loose stools following lactulose administration is to monitor the client's mental status. Lactulose is given to lower serum ammonia levels in hepatic encephalopathy, and loose stools can be an expected side effect of its use. Monitoring mental status is crucial because changes in mental status, such as confusion or altered level of consciousness, are key indicators of hepatic encephalopathy worsening. Sending a stool specimen to the lab would not be the priority in this situation as loose stools are a known effect of lactulose. Measuring abdominal girth is more relevant for conditions like ascites, not loose stools. Encouraging increased fiber in the diet may be beneficial for constipation but is not the immediate action needed when loose stools occur after lactulose administration.
4. A client with urticaria due to environmental allergies is taking diphenhydramine (Benadryl). Which complaint should the nurse identify as a side effect of this OTC medication?
- A. Nausea and indigestion.
- B. Hypersalivation.
- C. Eyelid and facial twitching.
- D. Increased appetite.
Correct answer: A
Rationale: The correct answer is A: Nausea and indigestion. Diphenhydramine, an antihistamine, commonly causes gastrointestinal side effects such as nausea and indigestion. These symptoms are often reported by individuals taking this medication. Choices B, C, and D are incorrect because hypersalivation, eyelid and facial twitching, and increased appetite are not typically associated with diphenhydramine use.
5. A client with a tracheostomy has thick, tenacious secretions. Which intervention should the nurse include in the plan of care?
- A. Encourage the client to drink plenty of fluids.
- B. Perform deep suctioning every 2 to 4 hours.
- C. Increase humidity in the client's room.
- D. Administer a mucolytic agent.
Correct answer: C
Rationale: Increasing humidity in the client's room can help liquefy thick secretions and facilitate easier airway clearance in a client with a tracheostomy. Encouraging the client to drink plenty of fluids can be beneficial for overall hydration but may not directly address thick secretions. Deep suctioning every 2 to 4 hours can be harmful and cause trauma to the airway lining. Administering a mucolytic agent should be done under the healthcare provider's order and may not be the initial intervention for thick secretions.
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