Question

A client who is one day postpartum reports to the nurse that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

Answer 1

Correct Answers:

Recommend using a breast shield.

Rationale :

🍼 Inverted nipples can interfere with newborn latching and early breastfeeding success.

🍼 A breast shield acts as a silicone interface that helps extend the nipple, promoting infant latch.

🍼 This non-invasive solution supports the goal of exclusive breastfeeding without introducing formula.

🍼 It allows the infant to stimulate the breast directly, encouraging milk production and supply.

🍼 It serves as an effective temporary aid until nipple eversion or latch improvement occurs.

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Answer 2

Correct Answers:

Recommend using a breast shield.

Rationale :

🩷 Inverted nipples may retract inward, making it hard for the infant to maintain suction.

🩷 A breast shield facilitates direct breastfeeding, avoiding early formula supplementation.

🩷 It prevents nipple confusion, which can occur with early bottle feeding.

🩷 This device also protects tender nipples while promoting suckling-induced nipple protrusion.

🩷 It is part of evidence-based lactation support for mothers with nipple anatomy challenges.

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Answer 3

Correct Answers:

Avoid acetylsalicylic acid-containing medications.

Rationale :

🧪 The client has gouty arthritis, which is exacerbated by substances that alter uric acid levels.

🧪 Acetylsalicylic acid (aspirin) inhibits uric acid excretion, raising serum urate concentrations.

🧪 This can trigger acute gout attacks, such as the sudden toe pain described in this client.

🧪 NSAIDs like indomethacin are preferred for managing gouty inflammation.

🧪 Teaching this avoids future exacerbations and promotes long-term joint preservation.

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Answer 4

Correct Answers:

Increased abdominal girth.

Rationale :

🟢 Ascites is the most likely cause of the 5 lb weight gain in a cirrhotic patient.

🟢 Fluid accumulation in the peritoneal cavity causes measurable abdominal distension.

🟢 This symptom aligns with common findings in advanced liver disease.

🟢 It reflects fluid retention, not fat or muscle gain, confirming weight gain is pathological.

🟢 Monitoring girth helps track fluid management effectiveness.

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Answer 5

Correct Answers:

Discuss ethical concerns about placebo use with the healthcare provider.

Rationale :

🔶 Patient autonomy is central in nursing ethics; using a placebo without consent violates this principle.

🔶 Nurses are ethically obligated to advocate for informed consent and protect clients from deception.

🔶 Placebo use without disclosure may breach trust, reduce compliance, and increase distress in clients.

🔶 By discussing concerns directly with the provider, the nurse initiates interprofessional collaboration to resolve the issue.

🔶 This action promotes professional accountability and ensures ethical standards are upheld in client care.

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Answer 6

Correct Answers:

Pull the pinna up and back to administer the drops.

Rationale :

🔷 This technique straightens the ear canal, ensuring accurate delivery of the medication.

🔷 Pulling the pinna up and back aligns the ear canal in adults for maximum penetration of the drops.

🔷 Proper positioning reduces the risk of retention or incomplete absorption of the medication.

🔷 This method helps avoid injury or contamination, unlike inserting the dropper directly.

🔷 Patient and caregiver education on this method improves home medication safety and efficacy.

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Answer 7

Correct Answers:

Urinary output of 30 to 60 mL/hr.

Rationale :

🟢 Adequate renal function is required to safely administer potassium-containing IV fluids.

🟢 A urine output of 30–60 mL/hr indicates that the kidneys can excrete potassium and prevent accumulation.

🟢 Hyperkalemia is a life-threatening complication that can result if the kidneys fail to eliminate potassium.

🟢 In clients with DKA, renal function may fluctuate; thus, urine output is the most reliable marker before infusion.

🟢 This assessment aligns with safety protocols and ensures safe fluid and electrolyte replacement therapy.

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Answer 8

Correct Answers:

Question the client about the frequency of falls in recent months.

Rationale :

🟡 Fall history is a key component of a functional assessment, especially in older adults post-hospitalization.

🟡 Frequent falls indicate reduced mobility, balance issues, or cognitive decline, which impact rehabilitation needs.

🟡 This question helps identify risk for injury, allowing for early intervention with assistive devices or therapy.

🟡 Assessing fall history also reflects functional status and independence levels, informing discharge planning.

🟡 It ensures that appropriate precautions are integrated into the client's rehabilitation goals.

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Answer 9

Correct Answers:

Observe the color of urine.

Rationale :

🔴 Prasugrel is an antiplatelet medication with a significant risk for bleeding, including internal hemorrhage.

🔴 Hematuria or dark-colored urine may be early signs of bleeding in the urinary system.

🔴 Monitoring urine output and color can provide non-invasive clues to adverse drug effects.

🔴 Recognizing this subtle symptom can lead to early intervention and prevention of complications.

🔴 This practice reflects comprehensive monitoring of anticoagulant therapy for safety.

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Answer 10

Correct Answers:

Ask the client to describe the pain.

Rationale :

🟠 The subjective description of pain provides detailed insight into quality (e.g., sharp, aching, burning).

🟠 Verbal pain characterization helps tailor treatment plans for chronic conditions like osteoarthritis.

🟠 Clients' narratives reveal functional impact and response to prior interventions.

🟠 Asking directly promotes client-centered care and therapeutic communication.

🟠 Quality descriptors (e.g., dull, throbbing) support more accurate diagnoses and pain scale correlation.

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RN HESI Exit(with NGN)~2023 Exam 2

No.

1 :
A client who is one day postpartum reports to the nurse that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

2 :
A client who is one day postpartum reports that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

4 :
A client with cirrhosis of the liver reports a 5 lb (2.3 kg) weight gain within the last week during a physical assessment. Which assessment finding correlates with the client's report?

5 :
The healthcare provider prescribes a placebo instead of pain medication. Which intervention should the nurse implement?

6 :
The healthcare provider prescribes ear drops to an adult client with an ear infection. Which teaching should the nurse provide?

7 :
A client with type 1 diabetes mellitus (DM) is admitted in diabetic ketoacidosis. Treatment is initiated, and the nurse is preparing to administer IV fluids containing potassium chloride. Which assessment data is most important for the nurse to obtain before starting the infusion?

8 :
An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

9 :
Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care?

10 :
The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking due to increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?

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RN HESI Exit(with NGN)~2023 Exam 2

No.

1 : A client who is one day postpartum reports to the nurse that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

2 : A client who is one day postpartum reports that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

4 : A client with cirrhosis of the liver reports a 5 lb (2.3 kg) weight gain within the last week during a physical assessment. Which assessment finding correlates with the client's report?

5 : The healthcare provider prescribes a placebo instead of pain medication. Which intervention should the nurse implement?

6 : The healthcare provider prescribes ear drops to an adult client with an ear infection. Which teaching should the nurse provide?

7 : A client with type 1 diabetes mellitus (DM) is admitted in diabetic ketoacidosis. Treatment is initiated, and the nurse is preparing to administer IV fluids containing potassium chloride. Which assessment data is most important for the nurse to obtain before starting the infusion?

8 : An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

9 : Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care?

10 : The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking due to increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?

1 :
A client who is one day postpartum reports to the nurse that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

2 :
A client who is one day postpartum reports that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

4 :
A client with cirrhosis of the liver reports a 5 lb (2.3 kg) weight gain within the last week during a physical assessment. Which assessment finding correlates with the client's report?

5 :
The healthcare provider prescribes a placebo instead of pain medication. Which intervention should the nurse implement?

6 :
The healthcare provider prescribes ear drops to an adult client with an ear infection. Which teaching should the nurse provide?

7 :
A client with type 1 diabetes mellitus (DM) is admitted in diabetic ketoacidosis. Treatment is initiated, and the nurse is preparing to administer IV fluids containing potassium chloride. Which assessment data is most important for the nurse to obtain before starting the infusion?

8 :
An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

9 :
Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care?

10 :
The nurse is caring for an older adult client with a history of osteoarthritis who is having difficulty walking due to increased right knee pain. To assess the quality of the client's knee pain, which approach should the nurse use?