A client's subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next?

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HESI RN Exit Exam 2023 Questions

Question 1 of 5

A client's subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next?

Correct Answer: A

Rationale: The correct action for the nurse to implement next is to collect a clean-catch specimen. This is essential to diagnose the cause of the client's symptoms accurately before initiating any treatment. Administering antibiotics (Choice B) without confirming the diagnosis through a specimen collection can be inappropriate and potentially harmful. Performing a bladder scan (Choice C) may not provide the necessary information to identify the specific cause of the symptoms. Increasing the client's fluid intake (Choice D) is a general recommendation and may not address the underlying issue causing the symptoms.

Question 2 of 5

An older male client with a history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first?

Correct Answer: A

Rationale: The correct answer is to identify pills in the bag first. This is essential to ensure the client is taking the correct medications and to prevent any potential medication errors. Reviewing the client's medication schedule (choice B) can come after identifying the pills to cross-reference the medications. Assessing the client's symptoms (choice C) is important but should follow identifying the medications. Educating the client about proper medication usage (choice D) is crucial but should be done after confirming the medications in the bag.

Question 3 of 5

Which class of drugs is the only source of a cure for septic shock?

Correct Answer: B

Rationale: The correct answer is B: Anti-infectives. Anti-infective agents, such as antibiotics, are essential in treating septic shock as they can eliminate bacteria and halt the progression of the condition by stopping the production of endotoxins. Antihypertensives (Choice A) are used to lower blood pressure, antihistamines (Choice C) are used to treat allergic reactions, and anticholesteremics (Choice D) are used to lower cholesterol levels. However, none of these drug classes directly address the bacterial infection that underlies septic shock.

Question 4 of 5

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.

Question 5 of 5

The nurse is assessing a primigravida at 39-weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider?

Correct Answer: A

Rationale: A fetal heart rate of 200 beats per minute is significantly elevated and requires immediate medical attention. This finding could indicate fetal distress, tachycardia, or other serious issues that need prompt evaluation. Mild ankle edema, complaints of back pain, and decreased fetal movements are common in pregnancy but are not as urgent or concerning as a high fetal heart rate.

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