HESIEXIT
RN2024
V3
160
Questions
1.Amaleclientwithstomachcancerreturnstotheunitfollowingatotalgastrectomy.Hehasa
nasogastrictubetosuctionandisreceivingLactatedRinger’ssolutionat75mL/hourIV.One
hourafteradmissiontotheunit,thenursenotes300mLofbloodinthesuctioncanister,the
client’sheartrateis155beats/minute,andhisbloodpressureis78/48mmHg.Inadditionto
reportingthefindingtothesurgeon.Whichactionshouldthenurseimplementfirst?
a.Measureanddocumenttheclient’surinaryoutput.
b.Requesttheclient’sreservedunitifpackedredbloodcells.
c.Preparetheplacementofacentralvenouscatheter.
d.IncreasetheinfusionrateofLactatedRinger’ssolution.
2.anadultmalewhofell20feetfromtheroofofthishomehasmultipleinjuries,includingaright
pneumothorax.Chesttubeswereinsertedintheemergencydepartmentpriortohistransferto
theintensivecareunit(ICU).thenursenotesthatthesuctioncontrolchamberisbubblingatthe
-10cmH2Omark,withfluctuationinthewaterseal,andoverthepasthour75mlofbrightred
bloodismeasuredinthecollectionchamber.Whichinterventionshouldthenurseimplement?
a.Addsterilewatertothesuctioncontrolchamber.
b.Givebloodfromthecollectionchamberasautotransfusion
c.Manipulatebloodintubingtodrainintochamber.
d.Increasewallsuctiontoeliminatefluctuationinwaterseal.
3.Aclientwhoreceivedhemodialysisyesterdayisexperiencingabloodpressureof200/100
mmHg,heartrate110beats/minute,andrespiratoryrate36breaths/minute.Theclientis
manifestingshortnessofbreath,bilateral2+pedaledema,andanoxygensaturationonroomair
of89%.Whichactionshouldthenursetakefirst?
a.Elevatethefootofthebed.
b.Restricttheclient’sfluid.
c.Beginsupplementaloxygen.
d.Preparetheclientforhemodialysis.
4.AclientwithAddison’scrisisisadmittedfortreatmentwithadrenalcorticalsupplementation.
Basedontheclient’sadmittingdiagnosis,whichfindingsrequireimmediateactionbythenurse?
(Selectallthatapply)
a.Headacheandtremors
b.Irregularheartrate
c.Skinhyperpigmentation
d.Posturalhypotension
e.Palloranddiaphoresis
