HESI 799 RN Exit Exam Quizlet

HESI 799 RN Exit Exam Quizlet Related

Review HESI 799 RN Exit Exam Quizlet related questions and content

The nurse and an unlicensed assistive personnel (UAP) are providing care for a client with a nasogastric tube (NGT) when the client begins to vomit. How should the nurse manage this situation?

  • A. Direct the UAP to measure the emesis while the nurse irrigates the NGT
  • B. Stop the NGT feed and notify the healthcare provider
  • C. Increase the NGT suction pressure
  • D. Elevate the head of the bed
Correct Answer: A

Rationale: During vomiting in a client with an NGT, it is essential for the nurse to direct the UAP to measure the emesis to monitor the output. This helps in assessing the client's condition and response to treatment. Meanwhile, irrigating the NGT can be beneficial to relieve any obstruction that might be contributing to the vomiting. Stopping the NGT feed and notifying the healthcare provider (choice B) is important but not the immediate action needed. Increasing the NGT suction pressure (choice C) is unnecessary and can lead to complications. Elevating the head of the bed (choice D) is a general intervention to prevent aspiration but may not address the immediate issue of managing the vomiting episode and potential tube obstruction.

You may also like to solve these questions

The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete?

  • A. Auscultate the client's bowel sounds
  • B. Observe for edema around the ankles
  • C. Measure the client's capillary glucose level
  • D. Count the apical and radial pulses simultaneously
Correct Answer: A

Rationale: The correct answer is to auscultate the client's bowel sounds. Hydromorphone is a potent opioid analgesic that can slow peristalsis and commonly cause constipation. By assessing the client's bowel sounds, the nurse can monitor for any signs of decreased bowel motility or potential constipation. Observing for edema (Choice B) is not directly related to hydromorphone administration. Measuring capillary glucose levels (Choice C) is not the priority in this situation. Counting the apical and radial pulses simultaneously (Choice D) is not specifically indicated in this scenario involving hydromorphone administration.

A client with cirrhosis is admitted with hepatic encephalopathy. Which laboratory value is most concerning?

  • A. Serum ammonia level of 100 mcg/dl
  • B. Bilirubin level of 3.0 mg/dl
  • C. Prothrombin time of 18 seconds
  • D. Serum sodium level of 135 mEq/L
Correct Answer: A

Rationale: A serum ammonia level of 100 mcg/dl is most concerning in a client with hepatic encephalopathy. Elevated serum ammonia levels indicate significant liver dysfunction and an increased risk of worsening encephalopathy. Bilirubin level and prothrombin time are important in assessing liver function, but in the context of hepatic encephalopathy, elevated ammonia levels take precedence as they directly contribute to neurological symptoms. Serum sodium level, though important, is not the primary concern when managing hepatic encephalopathy.

When administering ceftriaxone sodium (Rocephin) intravenously to a client, which assessment finding requires the most immediate intervention by the nurse?

  • A. Stridor
  • B. Nausea
  • C. Headache
  • D. Pruritus
Correct Answer: A

Rationale: The correct answer is A: Stridor. Stridor is a high-pitched, noisy breathing sound that indicates a potential airway obstruction, which can be caused by an allergic reaction. This finding requires immediate intervention by the nurse to ensure the client's airway is patent and to prevent respiratory distress. Nausea, headache, and pruritus are potential side effects of ceftriaxone sodium but do not pose immediate life-threatening risks compared to airway obstruction indicated by stridor.

A client with a history of rheumatoid arthritis is prescribed prednisone. Which assessment finding requires immediate intervention?

  • A. Increased joint pain
  • B. Weight gain of 2 pounds in 24 hours
  • C. Blood glucose level of 150 mg/dl
  • D. Fever of 100.4°F
Correct Answer: B

Rationale: The correct answer is B. Weight gain of 2 pounds in 24 hours is concerning in a client with rheumatoid arthritis on prednisone as it may indicate fluid retention or worsening heart failure. Increased joint pain, blood glucose level of 150 mg/dl, and fever of 100.4°F are important assessments but do not require immediate intervention compared to the potential severity of rapid weight gain.

The nurse is caring for a client with a chest tube following a pneumothorax. Which finding requires immediate intervention?

  • A. Oxygen saturation of 94%
  • B. Crepitus around the insertion site
  • C. Subcutaneous emphysema
  • D. Drainage of 50 ml per hour
Correct Answer: C

Rationale: Subcutaneous emphysema is the most critical finding requiring immediate intervention in a client with a chest tube following a pneumothorax. It may indicate a pneumothorax recurrence or air leak, which can lead to respiratory compromise. Oxygen saturation of 94% is slightly low but may not require immediate intervention. Crepitus around the insertion site can be a normal finding post-procedure. Drainage of 50 ml per hour is within the expected range for a chest tube output and does not indicate an immediate concern.

Copyright © 2025 Nokea. All rights reserved.