HESI RN Exit V2

HESI RN Exit V2 The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns that the client has a current blood glucose level of 720 mg/dL. When assessing the client, what is the priority? A. Assess for signs of fluid volume deficit B. Observe wound drainage characteristics C. Measure the level of acute pain D. Determine when the client last ate - ANS-A. Assess for signs of fluid volume deficit A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and dull gnawing pain that is relieved when he eats. Which is the best response by the nurse? A. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer B. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food C. Instruct the client that these mild symptoms can generally be controlled with changes in his diet D. Advise the client that he needs to seek immediate medical evaluation and treatment of these symptoms - ANS-A. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hr IV. One hour after admission to the unit, the nurse notes 300mL of blood in the suction canister, the client's heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the findings to the surgeon, which action should the nurse implement first? A. Measure and document the client's urinary output B. Request the client's reserved unit of packed red blood cells C. Prepare for placement of a central venous catheter D. Increase the infusion rate of Lactated Ringer's solution - ANS-D. Increase the infusion rate of Lactated Ringer's solution A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the heparin solution as 18 units/kg/hour. The available solution is Heparin Sodium 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program the infusion pump to deliver how many mL/hour? - ANS--1st: calculate the weight = 220/2.2= 100kg -Then calculate total dose in units = 18units x 100kg = 1800 units/hr - 25000 units - in 250 1800 units ---in X ml x = 1800 x 250/25000 =18 mL/hr An adult male who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse notes that the suction control chamber is bubbling at the -10cm H2O mark, which fluctuation in the water seal, and over the past hour 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? A. Add sterile water to the suction control chamber B. Give blood from the collection chamber as autotransfusion C. Manipulate blood in tubing to drain into chamber D. Increase wall suction to eliminate fluctuation in water seal - ANS-A. Add sterile water to the suction control chamber An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. Which is the best response by the nurse? A. Gather information regarding how long it will take for the children to arrive B. Explain that the client will start to lose consciousness and the body systems will slow down C. Reassure the spouse that the healthcare provider will notify when to call the children D. Offer to discuss the client's health status with each of the adult children - ANS-B. Explain that the client will start to lose consciousness and the body systems will slow down The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)? A. A 48-year-old marathon runner with a central venous catheter who is experiencing nausea and vomiting due to electrolyte disturbance following a race B. A 34-year-old admitted today after an emergency appendectomy who has a peripheral intravenous catheter and a Foley catheter C. A 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen via nasal cannula and has a saline-locked peripheral intravenous catheter D. An 82-year-old client with Alzheimer's disease and a newly-fractured femur who has a Foley catheter and soft wrist restraints applied - ANS-D. An 82-year-old client with Alzheimer's disease and a newlyfractured femur who has a Foley catheter and soft wrist restraints applied The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mcg/2.4mL". How many mL should the nurse administer? Round to nearest tenth. - ANS-0.2 mL In caring for a client with Cushing's Syndrome, which serum laboratory value is most important for the nurse to monitor? A. Creatinine B. Lactate C. Glucose D. Hemoglobin - ANS-C. Glucose A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which action should the nurse take first? A. Elevate the foot of the bed B. Restrict the client's fluids C. Begin supplemental oxygen D. Prepare client for hemodialysis - ANS-C. Begin supplemental oxygen CONTINUES...