the nurse is assessing a client with chronic kidney disease ckd who is receiving erythropoietin therapy which laboratory value should the nurse monito
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HESI RN

HESI RN Exit Exam 2024 Quizlet

1. The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should the nurse monitor closely?

Correct answer: A

Rationale: In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, the nurse should closely monitor the serum potassium level. Erythropoietin therapy can increase red blood cell production, leading to a higher demand for potassium. Monitoring potassium levels is crucial to prevent hyperkalemia, a potential risk associated with this therapy. Hemoglobin level (Choice B) is important to assess the effectiveness of erythropoietin therapy, but monitoring potassium levels takes precedence due to the risk of hyperkalemia. White blood cell count (Choice C) and serum calcium level (Choice D) are not directly affected by erythropoietin therapy in the context of chronic kidney disease.

2. A client with a history of chronic alcoholism is admitted with confusion, ataxia, and diplopia. Which nursing intervention is a priority for this client?

Correct answer: B

Rationale: The correct answer is to administer thiamine as prescribed. This intervention is a priority for clients with chronic alcoholism to prevent Wernicke's encephalopathy, a serious complication of thiamine deficiency. Monitoring for signs of alcohol withdrawal (choice A) is important but not the priority in this scenario. Providing a quiet environment (choice C) may be beneficial but does not address the immediate need to prevent Wernicke's encephalopathy. Initiating fall precautions (choice D) is also important but not the priority compared to administering thiamine to prevent a life-threatening condition.

3. When obtaining a rectal temperature with an electronic thermometer, which action is most important for the nurse to perform?

Correct answer: A

Rationale: When obtaining a rectal temperature with an electronic thermometer, holding the thermometer in place is crucial. This action ensures accurate temperature measurement and prevents injury to the client. Option B, placing a disposable pad under the buttocks, is not the most important action; it may enhance comfort but does not impact the accuracy of the temperature reading. Option C, instructing the client to breathe deeply, is irrelevant to obtaining a rectal temperature. Option D, returning the probe to the charger, is an incorrect action after temperature measurement.

4. To reduce the risk of being named in a malpractice lawsuit, which action is most important for the nurse to take?

Correct answer: A

Rationale: Adhering consistently to standards of care is crucial for nurses to reduce the risk of being named in a malpractice lawsuit. Following established protocols and guidelines ensures that the care provided is safe and effective. Thoroughly documenting all client interactions is also essential to support the care provided and to have a record of the interventions. Building a good rapport with clients is important for communication and trust but does not directly reduce the risk of malpractice. Working closely with the healthcare team is valuable for collaboration but might not directly impact the risk of malpractice unless it relates to following standards of care.

5. The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider?

Correct answer: B

Rationale: Rebound tenderness in the upper quadrants may indicate peritonitis, which requires prompt medical attention. Hypoactive bowel sounds are expected in small bowel obstruction and would not be a priority over signs of peritonitis. Tympany with percussion is a normal finding and not a cause for immediate concern. Light-colored gastric aspirate could indicate various issues but is not as urgent as peritonitis.

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