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?

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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: Failed to generate a rationale of 500+ characters after 5 retries.

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.

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