Review HESI RN EXIT 3 (2024)

Determine apical pulse rate and rhythm. Hyperkalemia can cause life-threatening cardiac dysrhythmias, including bradycardia, heart block, and ventricular tachycardia. Assessing the apical pulse rate and rhythm can provide essential information about cardiac function and help identify potential dysrhythmias.

Assess strength of deep tendon reflexes. Hyperkalemia can affect neuromuscular function, leading to hyperreflexia or diminished reflexes. While assessing deep tendon reflexes isimportant, it is not as critical as assessing cardiac function in a client with known hyperkalemia.

Observe color and amount of urine. While changes in urinary output and characteristics may indicate renal impairment associated with hyperkalemia, the priority in this situation is to assess for cardiac manifestations of hyperkalemia.

Risk for aspiration relative to muscle weakness. Parkinson's disease can cause muscle weakness and impaired swallowing function, leading to an increased risk of aspiration.Aspiration pneumonia is a severe complication that requires immediate attention, making this the highest priority nursing problem.

Risk for constipation relative to immobility. Constipation is a common problem in Parkinson's disease due to immobility and medication side effects. While constipation should be addressed, it is not as immediately life-threatening as the risk for aspiration.

Impaired physical mobility relative to muscle rigidity. Impaired physical mobility is a significant concern in Parkinson's disease, but muscle rigidity does not necessarily pose animmediate risk of aspiration. Addressing impaired mobility is important for maintaining overall function and quality of life but may not be the highest priority in this scenario.

This instruction is incorrect because it does not involve the collection of a complete 24-hour urine specimen. Collecting specimens every 6 hours would not provide an accurate measurement of creatinine clearance over a 24-hour period.

This instruction is correct. For a 24-hour urine collection, the client should urinate at a specified time to start the collection period, discard this urine, and then collect all subsequent urine produced over the next 24 hours. This ensures that the entire 24-hour period is captured for analysis.

This instruction is incorrect because it does not involve the collection of all urine produced over a 24-hour period. Additionally, discarding the first portion of voiding is not necessary for a creatinine clearance test and may lead to inaccurate results.

Initiate seizure precautions. Severe agitation and tremors can be signs of benzodiazepine withdrawal, which may progress to seizures. Initiating seizure precautions, such as ensuring asafe environment, padding side rails, and having emergency medications and equipment readily available, is the priority to prevent injury.

Obtain a serum drug screen. While obtaining a serum drug screen may be necessary to confirm benzodiazepine withdrawal, it is not the immediate action needed to address the client's current symptoms and prevent potential harm.

Administer naloxone per PRN protocol. Naloxone is an opioid antagonist used to reverse opioid overdose and is not indicated for benzodiazepine withdrawal. Administering naloxone would not be appropriate or effective in this situation.

Falling from a ladder as the reason for admission is relevant information, but it does not address the immediate clinical concern of the client's altered mental status.

Reporting the increasing confusion of the client is the priority as it highlights the acute change in neurological status, which may indicate a more critical issue such as intracranial injury or neurological impairment.

The client's healthcare power of attorney is important for long-term care planning, but it is not the immediate concern when the client presents with altered mental status and potential headtrauma.

Every 5 minutes for one hour is a shorter duration of monitoring compared to option A andmay not provide adequate time to detect and respond to any significant changes in blood pressure that could occur after paracentesis, especially considering the volume of fluid removed.

Every 15 minutes for one hour, then every 1 hour for 2 hours provides frequent monitoringinitially, but the interval between assessments is too long after the first hour, potentially missing early signs of complications such as hypovolemia.

Every 1 hour for 2 hours does not provide sufficient frequency of monitoring, especially during the critical immediate post-paracentesis period when rapid changes in blood pressure can occur. This schedule may delay the detection and management of complications.

Headache. Headache is a common symptom of preeclampsia and should be reported to the healthcare provider, especially if it is severe or persistent.

Blurred vision. Blurred vision or other visual disturbances can be signs of preeclampsia and should be reported to the healthcare provider for evaluation.

Lack of appetite. While lack of appetite can occur in preeclampsia, it is not a primary indicator of the condition and may be influenced by other factors.

Chills and fever. Chills and fever are not typical symptoms of preeclampsia and may indicate an infection rather than preeclampsia.

Urinary frequency. Urinary frequency is not typically associated with preeclampsia unless it is accompanied by other symptoms such as proteinuria or hypertension. It may be a normal
symptom of pregnancy.

Suggesting participation in a team sport may not be suitable for a child with duch*enne muscular dystrophy, as team sports often involve physical exertion and may increase fatigue and risk of injury.

Explaining that the child is too young to understand the risks associated with swimming is not an appropriate response. Children with duch*enne muscular dystrophy and their parents should be educated about the condition and involved in decision-making regarding physical activities.

Encouraging the parents to allow the child to continue attending swimming lessons with supervision may not be safe, as swimming can be physically demanding and may increase the risk of fatigue and injury in a child with duch*enne muscular dystrophy. Supervision alone may not mitigate these risks.

While activity restriction may indirectly help decrease abdominal pain by reducing inflammation and promoting healing, it is not the primary purpose of the restriction.

Activity restriction may help reduce intestinal activity by allowing the intestines to rest and heal, but the main goal is to promote healing rather than directly reducing intestinal activity.

While activity restriction may help control diarrhea episodes by reducing physical stress on the intestines, the primary purpose is to promote healing and reduce inflammation. Control of diarrhea may be achieved through other interventions such as dietary modifications andmedication management.

Wear protective goggles while performing the procedure. Excessive drooling in a client with ALS may increase the risk of exposure to saliva and potential aerosolized droplets duringsuctioning. Wearing protective goggles helps prevent exposure to bodily fluids and reduces the risk of infection for the nurse.

Instill 3 mL of normal saline before suctioning. Instilling normal saline before suctioning is not typically indicated for oral suctioning in a client with excessive drooling. This action may increase the risk of aspiration and is unnecessary for managing drooling.

Instruct the client to cough as the suction tip is removed. Instructing the client to cough is not appropriate for oral suctioning. Coughing may increase the production of saliva and exacerbate drooling. Additionally, this action does not address the nurse's safety during the suctioningprocedure.

Express a small amount of breast milk by hand. While hand expression can help relieve engorgement, it may also stimulate further milk production, leading to increased engorgement. This recommendation may not be sufficient for managing severe engorgement.

Place warm packs on both breasts. Warm packs can increase blood flow and may provide temporary relief from discomfort, but they are not the most effective intervention for breast engorgement. Warmth can also increase inflammation and swelling in some cases.

Take a prescribed analgesic and expose breasts to air. Taking a prescribed analgesic can help relieve pain associated with breast engorgement, while exposing the breasts to air allows forcooling and may reduce swelling. This recommendation addresses both pain relief and management of engorgement symptoms.

Auscultating the femoral region would not yield information about carotid bruits. The femoral region pertains to the upper thigh area and is not anatomically related to the carotid artery.

The cubital fossa is the inner elbow region and is not associated with auscultation for carotid bruits. It is typically used for auscultation of blood pressure using the brachial artery.

The navel (belly button) is not a relevant location for auscultation for carotid bruits. It is far from the carotid arteries and would not provide any meaningful information about carotid artery sounds.

Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment.Positioning the client is important for maintaining airway patency, but it is not the priority when assessing and managing acute stroke. Immediate interventions to address potential thrombolytic therapy take precedence.

Begin continuous observation for transient episodes of neurologic dysfunction. Continuous observation is important for monitoring the client's neurological status, but it is not the first action to take. The client requires urgent diagnostic imaging to confirm the diagnosis anddetermine eligibility for thrombolytic therapy.

Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy. This is the priority action. IV access is crucial for administering medications and fluids, and reviewing the inclusion criteria for IV fibrinolytic therapy is essential to determine if the client meets thecriteria for this time-sensitive intervention.

An adult client with a rectal tube draining clear, pale red liquid drainage. The presence of pale red drainage can indicate a potential issue that needs monitoring, such as bleeding or other complications, thus requiring a more timely assessment.

An older client with a distended abdomen and no drainage from the nasogastric tube. A distended abdomen and lack of drainage could indicate a blockage or other serious issue that needs immediate attention.

An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac. Dark red drainage can indicate active bleeding, which is a critical issue that needs to be addressed promptly to prevent complications.

Avoid administration of oxygen at high levels for extended periods. This is the correct principle. Prolonged exposure to high levels of oxygen can lead to oxygen toxicity, which can cause lung damage. Oxygen therapy should be titrated to maintain adequate oxygenation without exposing the patient to excessive oxygen levels.

Increase oxygen rate during sleep to compensate for slower respiratory rate. This statement is incorrect. Oxygen therapy should be adjusted based on the patient's oxygen saturation levels and respiratory status, not solely on sleep patterns.

Taking a sedative at bedtime slows respiratory rate, which decreases oxygen needs. While sedatives can depress respiratory rate, leading to decreased oxygen needs, this is not a general principle of oxygen administration. Oxygen therapy should be based on the patient's oxygenation needs rather than medications they are taking.

Determine if the client has recently experienced a fall. Falls can lead to head injuries or other trauma that may cause confusion or changes in behavior in older adults.

Provide instruction on taking the client's temperature. Fever can be a sign of infection, which might be causing the sudden behavioral changes. Monitoring temperature can help identify if an infection is present.

Encourage increased intake of high protein foods. While good nutrition is important, it is not directly related to the sudden onset of confusion and agitation, making this a less immediate priority.

Document abdominal girth. Documenting abdominal girth is important to assess for signs of ascites, which can occur in hepatic failure. A sudden weight gain and elevated blood pressure may indicate fluid retention, and documenting abdominal girth can provide additional information about fluid accumulation in the abdomen.

Offer a high protein diet. While nutritional support is important for clients with hepatic failure, offering a high protein diet may not be appropriate if the client has an electrolyte imbalance. Protein intake should be balanced and monitored carefully to avoid exacerbating the imbalance.

Use a cushion when sitting. Using a cushion when sitting may be beneficial for comfort, but it does not directly address the identified issues of electrolyte imbalance, elevated blood pressure, and weight gain. The priority is to assess and address these concerns through appropriateinterventions such as documenting abdominal girth and addressing fluid retention.

Apply an Internal fetal heart monitor. While continuous monitoring is important, the first priority is to address the immediate fetal distress. Monitoring alone will not address the issue.

Notify the healthcare provider. Notifying the provider is important, but addressing the immediate fetal distress takes priority.

Use a vibroacoustic stimulator. Vibroacoustic stimulation can be used to assess fetal well- being, but it does not address the underlying fetal distress, which is the priority.

Drinks more fluids than previously. Increased thirst (polydipsia) is a classic symptom of type 1 diabetes due to high blood sugar levels causing dehydration.

Voids only one or two times per day. Increased urination (polyuria) is a common symptom of type 1 diabetes as the body attempts to excrete excess glucose, so decreased urination is unlikely.

Refuses to eat favorite meals at home. While changes in appetite can occur, it is not a primary symptom of type 1 diabetes. Increased hunger (polyphagia) is more typical.

Ask the UAP to take the blood pressure in the other arm. This is the appropriate action.Spasms in the hand and fingers during blood pressure measurement could indicate vascular orneurological issues in that arm. Taking the blood pressure in the other arm can help determine if the spasms are related to the positioning or pressure of the cuff.

Administer a PRN antianxiety medication. Spasms in the hand and fingers during blood pressure measurement are not typically indicative of anxiety. Administering an antianxiety medication would not address the underlying issue and may not be appropriate.

Review the client's serum calcium level. While low serum calcium levels can cause muscle spasms, assessing serum calcium levels would not be the first step in addressing spasms during blood pressure measurement. This action may be considered if other potential causes are ruled out.