Question

A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

Answer 1

Correct Answers:

Measure urinary output every hour

Rationale :

🔷 Dopamine, at moderate doses (5–10 mcg/kg/min), primarily stimulates dopaminergic and beta-1 adrenergic receptors, improving renal perfusion and cardiac output.

🔷 Hourly urinary output monitoring is essential to assess renal function and perfusion effectiveness, especially in hypotensive patients.

🔷 Adequate urine output (≥0.5 mL/kg/hr) indicates that dopamine is successfully increasing renal blood flow.

🔷 A drop in urinary output may signal renal hypoperfusion or worsening hypotension, requiring immediate evaluation.

🔷 Monitoring also helps guide fluid resuscitation and titration of dopamine to achieve hemodynamic targets.

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Answer 2

Correct Answers:

Watery diarrhea

Rationale :

🔹 Linezolid is an oxazolidinone antibiotic with serious potential side effects, including Clostridioides difficile–associated diarrhea.

🔹 Watery or persistent diarrhea may indicate C. diff infection, a life-threatening complication requiring immediate intervention.

🔹 If left unrecognized, it may lead to severe colitis, sepsis, or toxic megacolon.

🔹 The nurse must promptly report and isolate the patient, discontinue the offending drug, and prepare for stool culture or toxin assay.

🔹 Other side effects (e.g., nausea, headache) are common but less emergent compared to possible antibiotic-associated colitis.

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Answer 3

Correct Answers:

Tell the client to have someone bring him to an emergency department immediately.

Rationale :

🔸 Lisinopril is an ACE inhibitor, and facial flushing may be a sign of angioedema, a rare but potentially life-threatening side effect.

🔸 Angioedema can progress to airway compromise with swelling of the lips, face, tongue, or throat—even in the absence of chest pain.

🔸 The client took a double dose (20 mg), increasing the risk of this reaction, especially if new to the medication.

🔸 Immediate evaluation is required to assess for airway involvement, oxygenation, and need for epinephrine or airway protection.

🔸 This is a medical emergency, and reassuring or home management is unsafe without ruling out anaphylactic-like complications.

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Answer 4

Correct Answers:

Keep chest tube container below the site of insertion.

Rationale :

🟪 During transport of a client with a chest tube, it is critical to maintain the gravity drainage system by keeping the chest tube collection container below chest level.

🟪 This ensures effective drainage of air or fluid and prevents backflow into the pleural cavity, which can cause pneumothorax or infection.

🟪 The chest tube system must remain upright, unobstructed, and not clamped, even during movement.

🟪 Securing the container but not the tubing to the stretcher allows for natural movement while preserving negative pressure.

🟪 Monitoring the drainage during and after transport helps detect changes in volume, color, or consistency—which can signal complications.

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Answer 5

Correct Answers:

Withhold this dose.

Rationale :

🔷 If a child vomits shortly after taking digoxin, it is not safe to redose without further evaluation because digoxin has a narrow therapeutic index.

🔷 Vomiting is also an early sign of digoxin toxicity, so repeating the dose might worsen toxicity or cause cardiac arrhythmias.

🔷 Parents should never give an extra dose without provider instruction, especially in infants.

🔷 The next scheduled dose should be given at its normal time, and the nurse should notify the provider about the incident.

🔷 Nurses must educate caregivers that if vomiting occurs after administration, the safest action is to withhold and report the event, not repeat the dose.

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Answer 6

Correct Answers:

Observe insertion site.

Rationale :

🔹 A suprapubic catheter is inserted directly into the bladder via the lower abdomen and is prone to infection or skin breakdown at the insertion site.

🔹 Regular visual inspection helps identify early signs of infection, such as redness, swelling, drainage, or bleeding.

🔹 Nurses must assess for leakage, dislodgement, or granulation tissue, which may compromise catheter function or cause discomfort.

🔹 Observation ensures that the catheter is well-secured and unobstructed, which is essential for consistent urine output.

🔹 This site check is critical in home health where early complications can be caught before they become emergencies.

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Answer 7

Correct Answers:

Ensure the client receives frequent small meals containing complete proteins

Rationale :

🔸 A serum albumin level of 1.5 g/dL is critically low and indicates severe malnutrition or protein loss, especially concerning in a patient on peritoneal dialysis.

🔸 Low albumin increases the risk of edema, hypotension, and delayed wound healing, and is a strong predictor of poor outcomes in dialysis patients.

🔸 Frequent, high-protein meals help rebuild protein stores and maintain oncotic pressure, supporting vascular stability.

🔸 Since peritoneal dialysis leads to loss of proteins through the peritoneal membrane, adequate intake is essential to replenish them.

🔸 Nutritional support must focus on complete proteins (e.g., eggs, meat, dairy), which supply all essential amino acids for healing and immunity.

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Answer 8

Correct Answers:

Consume foods with saturated fats.
Use a salt substitute.
Eat more canned vegetables.

Rationale :

Consume foods with saturated fats:

🟪 Saturated fats contribute to atherosclerosis and progression of coronary artery disease (CAD).

🟪 These fats raise LDL cholesterol, the “bad” cholesterol, increasing cardiovascular risk.

🟪 Clients should be taught to consume unsaturated fats (e.g., olive oil, avocados) instead.

Use a salt substitute:

🟪 Many salt substitutes contain potassium chloride, which may be dangerous in patients with renal issues or on certain medications (e.g., ACE inhibitors).

🟪 The use of salt substitutes should be approved by a provider based on the client's full electrolyte and medication profile.

Eat more canned vegetables:

🟪 Canned vegetables often contain high sodium content, which increases blood pressure and fluid retention—both detrimental in CAD.

🟪 Clients should be encouraged to choose fresh or no-salt-added canned options and rinse canned items before use.

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Answer 9

Correct Answers:

Maintain a continuous infusion of IV fluids per prescription

Rationale :

🟫 In pyloric stenosis, infants suffer from projectile vomiting, leading to dehydration, electrolyte imbalances, and metabolic alkalosis.

🟫 Pre-op management focuses on restoring fluid and electrolyte balance before surgery can safely proceed.

🟫 IV fluids are typically supplemented with electrolytes (e.g., sodium, potassium, chloride) to correct deficits.

🟫 Maintaining fluid balance helps stabilize acid–base status and circulation, improving surgical outcomes.

🟫 Monitoring intake/output and electrolytes is vital, but IV fluid correction takes priority in immediate pre-op care.

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Answer 10

Correct Answers:

Provide supplemental oxygen.

Rationale :

🔷 Sudden chest pain and dyspnea in a post-op orthopedic client are classic signs of pulmonary embolism (PE), a life-threatening emergency.

🔷 The first action in suspected PE is to improve oxygenation by delivering supplemental oxygen, which helps reduce hypoxia.

🔷 PE causes ventilation-perfusion mismatch, impairing oxygen transfer and leading to hypoxemia if not corrected.

🔷 Oxygen is an immediate, low-risk intervention that can be provided while preparing for other actions (e.g., heparin infusion or imaging).

🔷 Delays in oxygenation may result in cardiac strain, arrhythmias, or shock, making this the top priority before contacting the provider.

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RN HESI Exit~2024 Exam 3

No.

1 :
A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

2 :
In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the health care provider?

3 :
A male client reports to the on-call clinic nurse that he took two tablets of 10 mg lisinopril by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any chest pain at the moment or recently .Which action should the nurse take?

4 :
A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?

5 :
A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her a-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

6 :
Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

8 :
The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s) made by the client should the nurse recognize as needing additional education? (Select all that apply.)

9 :
A 6-week-old infant with poor weight gain is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?

10 :
Two days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects the client had a pulmonary embolus. Which action should the nurse take first?

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RN HESI Exit~2024 Exam 3

No.

1 : A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

2 : In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the health care provider?

3 : A male client reports to the on-call clinic nurse that he took two tablets of 10 mg lisinopril by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any chest pain at the moment or recently .Which action should the nurse take?

4 : A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?

5 : A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her a-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

6 : Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

8 : The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s) made by the client should the nurse recognize as needing additional education? (Select all that apply.)

9 : A 6-week-old infant with poor weight gain is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?

10 : Two days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects the client had a pulmonary embolus. Which action should the nurse take first?

1 :
A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

2 :
In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the health care provider?

3 :
A male client reports to the on-call clinic nurse that he took two tablets of 10 mg lisinopril by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any chest pain at the moment or recently .Which action should the nurse take?

4 :
A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?

5 :
A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her a-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

6 :
Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

8 :
The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s) made by the client should the nurse recognize as needing additional education? (Select all that apply.)

9 :
A 6-week-old infant with poor weight gain is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?

10 :
Two days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects the client had a pulmonary embolus. Which action should the nurse take first?