HESI RN
HESI RN Exit Exam 2024 Quizlet Questions
Question 1 of 5
A female client reports that she drank a liter of a solution to cleanse her intestines but vomited immediately. How many ml of fluid intake should the nurse document?
Correct Answer: C
Rationale: In this scenario, the correct answer is C) 760 ml. The rationale behind this is based on understanding the concept of fluid intake and absorption. When the female client drank a liter of the solution but vomited immediately, it indicates that not all of the liquid was retained in her body. Therefore, the nurse should document the amount that was actually ingested, which is 760 ml. Option A) 240 ml is incorrect because the client consumed more liquid than this amount. Option B) 500 ml is also incorrect as the client consumed a liter, which is 1000 ml, not 500 ml. Option D) 1000 ml is not the correct answer in this case because the client vomited immediately after ingesting the solution, indicating that not all of the fluid remained in her system. Educationally, this question tests the nurse's knowledge of accurately documenting fluid intake in a clinical setting. It highlights the importance of understanding the relationship between intake, absorption, and retention of fluids in the body, particularly in situations where vomiting or other factors may affect the actual amount absorbed. This knowledge is crucial for providing optimal patient care and ensuring accurate documentation of fluid balance.
Question 2 of 5
During the initial visit to a client with MS who is bed-bound and lifted by a hoist, which intervention is most important for the nurse to implement?
Correct Answer: A
Rationale: During the initial visit, the most crucial intervention for the nurse is to determine how the client is cared for when the caregiver is not present. This is essential to ensure the client's safety and well-being, especially during times when the caregiver is not available. Option B is not the most important as it focuses on assessment rather than immediate safety concerns. Option C, while important, is secondary to ensuring continuous care. Option D is less critical during the initial visit compared to ensuring care continuity in the caregiver's absence.
Question 3 of 5
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.
Question 4 of 5
In determining the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition?
Correct Answer: C
Rationale: The correct answer is C: Orthopnea. If the client is orthopneic, the nurse needs to adapt the insertion position that does not place the client in a supine position. This means the head of the bed should be elevated as much as possible to facilitate catheter insertion without compromising the client's breathing. High urinary pH (choice A) is not directly relevant to the insertion position of a urinary catheter. Abdominal ascites (choice B) may impact the procedure due to abdominal distension but is not as crucial as orthopnea. Fever (choice D) does not specifically affect the client's position for urinary catheter insertion.
Question 5 of 5
Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective?
Correct Answer: A
Rationale: The correct answer is A: Decreased abdominal girth. In a client with cirrhosis of the liver, a LeVeen shunt is used to treat ascites, which is the accumulation of fluid in the peritoneal cavity. A decrease in abdominal girth indicates that the shunt is effectively draining the ascitic fluid, relieving the client's abdominal distension. Choice B, increased blood pressure, is incorrect as a LeVeen shunt is not expected to impact blood pressure. Choice C, clear breath sounds, is unrelated to the effectiveness of a LeVeen shunt in managing ascites. Choice D, decreased serum albumin, is also not a direct indicator of the shunt's effectiveness in draining ascitic fluid.