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 reviews the laboratory findings of a client with an open fracture of the tibia. The white blood cell (WBC) count and erythrocyte sedimentation rate (ESR) are elevated. Before reporting this information to the healthcare provider, what assessment should the nurse obtain?

  • A. Appearance of wound
  • B. Pain level
  • C. Presence of fever
  • D. Mobility status
Correct Answer: A

Rationale: The correct answer is A: Appearance of wound. Elevated WBC and ESR levels suggest a possible infection in the client with an open fracture. Assessing the wound's appearance is crucial to evaluate for signs of infection, such as redness, warmth, swelling, or drainage. By assessing the wound first, the nurse can provide important information to the healthcare provider regarding the potential infection, which may require immediate intervention. Choices B, C, and D are important assessments in caring for a client with an open fracture; however, in this scenario, the priority is to assess the wound for signs of infection due to the elevated WBC and ESR levels.

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A client with rheumatoid arthritis is prescribed methotrexate. Which assessment finding requires immediate intervention?

  • A. Fever of 100.4°F
  • B. Positive Chvostek's sign
  • C. Increased joint pain
  • D. Swelling in the joints
Correct Answer: B

Rationale: A positive Chvostek's sign indicates hypocalcemia, which requires immediate intervention as it can lead to life-threatening complications. Fever, increased joint pain, and swelling in the joints are common symptoms in clients with rheumatoid arthritis but do not require immediate intervention like addressing hypocalcemia.

The nurse is assessing a client with left-sided heart failure. Which finding requires immediate intervention?

  • A. Shortness of breath
  • B. Jugular venous distention
  • C. Crackles in the lungs
  • D. Peripheral edema
Correct Answer: C

Rationale: Crackles in the lungs indicate pulmonary congestion in a client with left-sided heart failure and require immediate intervention to prevent respiratory failure. Crackles suggest fluid accumulation in the lungs, leading to impaired gas exchange and potentially respiratory distress. Shortness of breath, jugular venous distention, and peripheral edema are common manifestations of heart failure but do not directly indicate acute respiratory compromise like crackles in the lungs do.

What is the first action the nurse should implement for a client admitted with acute pancreatitis?

  • A. Administer intravenous fluids as prescribed
  • B. Administer pain medication as prescribed
  • C. Place the client on NPO status
  • D. Assess the client's abdomen for distention
Correct Answer: C

Rationale: Placing the client on NPO status is the priority action for a client with acute pancreatitis. This step is crucial to rest the pancreas, prevent pancreatic stimulation, and decrease enzyme production. By withholding oral intake, the digestive system is given a chance to rest and recover. Administering intravenous fluids may be necessary but should come after placing the client on NPO status. Pain medication can be administered once the client is stabilized. Assessing the client's abdomen for distention is important but is not the initial priority in managing acute pancreatitis.

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

  • A. Serum potassium level
  • B. Hemoglobin level
  • C. White blood cell count
  • D. Serum calcium level
Correct Answer: A

Rationale: The correct answer is A: Serum potassium level. When a client with chronic kidney disease (CKD) is receiving erythropoietin therapy, the nurse should closely monitor the serum potassium level. Erythropoietin therapy can stimulate red blood cell production, leading to an increased demand for potassium. This increases the risk of hyperkalemia, making it crucial to monitor potassium levels closely. Choices B, C, and D are incorrect because erythropoietin therapy primarily affects red blood cell production, not hemoglobin, white blood cell count, or serum calcium levels.

A nurse is preparing to insert a nasogastric tube (NGT) in a client. Which action should the nurse take first?

  • A. Assess the client's history for nasal trauma or surgery
  • B. Ask the client to cough and deep breathe.
  • C. Measure the length of the tube to be inserted.
  • D. Explain the procedure to the client and obtain consent.
Correct Answer: D

Rationale: The correct first action for the nurse to take when preparing to insert a nasogastric tube (NGT) in a client is to explain the procedure to the client and obtain consent. It is crucial to ensure that the client is informed about the procedure, understands it, and consents to it before proceeding. Assessing the client's history for nasal trauma or surgery (Choice A) is important but can be done after obtaining consent. Asking the client to cough and deep breathe (Choice B) is not directly related to the initial step of preparing for NGT insertion. Measuring the length of the tube to be inserted (Choice C) is a necessary step but should come after explaining the procedure and obtaining consent.

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