Question

A client with a history of heart failure arrives at the emergency department describing an onset of fatigue and weakness. Theclient has been taking spironolactone 50 mg tablets PO every day.The nurse receives report from the lab that the client has a serum potassium level of 6.2 mEq/L (6.2 mmol/L). Which intervention is most important for the nurse to implement?

Answer 1

Correct Answers:

Determine apical pulse rate and rhythm.

Rationale :

💊 Spironolactone is potassium-sparing, and a serum potassium level of 6.2 mEq/L is dangerously elevated.

💊 Hyperkalemia can cause life-threatening cardiac arrhythmias, especially bradycardia or irregular rhythms.

💊 Monitoring the apical pulse provides the most accurate insight into cardiac rhythm changes caused by high potassium.

💊 An abnormal apical pulse may indicate the need for emergency interventions, such as ECG or medication adjustment.

💊 This action directly correlates with the client’s most critical risk—cardiac arrest due to electrolyte imbalance.

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Answer 2

Correct Answers:

Risk for aspiration relative to muscle weakness.

Rationale :

💎 Dysphagia and impaired gag reflex are common in Parkinson’s due to muscle rigidity and bradykinesia.

💎 Aspiration places the client at risk for pneumonia, a leading cause of morbidity in Parkinson’s disease.

💎 Prioritizing airway protection follows ABC (Airway, Breathing, Circulation) safety principles.

💎 This risk surpasses other concerns as it can cause acute respiratory compromise.

💎 Early identification allows for interventions like swallowing assessments or dietary modifications.

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Answer 3

Correct Answers:

Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours.

Rationale :

🕒 This method ensures the entire 24-hour creatinine output is measured accurately.

🕒 Discarding the first void standardizes the start time and prevents sample contamination.

🕒 Incomplete or incorrect collection skews glomerular filtration rate (GFR) results.

🕒 The test assesses renal function, crucial in clients with suspected or known kidney issues.

🕒 Proper collection ensures validity for calculating creatinine clearance and guiding therapy.

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Answer 4

Correct Answers:

Initiate seizure precautions.

Rationale :

Benzodiazepine withdrawal can result in life-threatening seizures, especially if abrupt.
Seizure precautions reduce injury risk and prepare staff for emergency intervention.
Clients withdrawing from alprazolam are at increased risk for CNS hyperexcitability.
Protecting the airway and minimizing harm during a seizure is a nursing safety priority.
This is the first step before medication or provider contact in acute agitation with tremors.

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Answer 5

Correct Answers:

Increasing confusion of the client.

Rationale :

🧾 SBAR communication begins with "Situation", which identifies the most urgent concern.

🧾 New or worsening confusion could signal neurological deterioration (e.g., head trauma, bleeding).

🧾 Altered mental status takes precedence in emergent conditions due to risk of brain injury.

🧾 The confusion reflects clinical deterioration, requiring immediate attention from the provider.

🧾 Identifying the acute issue promotes focused diagnostic and treatment efforts.

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Answer 6

Correct Answers:

Every 15 minutes for one hour, then every 1 hour for 2 hours.

Rationale :

Paracentesis removes fluid that can lead to sudden hypotension or hypovolemia.
Frequent monitoring allows early detection of hemodynamic instability.
Vital signs at 15-minute intervals provide insight into fluid shifts and perfusion.
Gradual decrease in monitoring frequency reflects stabilization over time.
Blood pressure monitoring is critical post-procedure to prevent shock or syncope.

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Answer 7

Correct Answers:

Swollen hands.
Headache.
Blurred vision.

Rationale :

Swollen hands

🔴 Swelling of the hands reflects generalized edema due to increased vascular permeability and fluid retention, which are hallmark signs of preeclampsia.

🔴 Edema may occur in the face, hands, and lower extremities, and is considered significant when it is sudden or excessive.

🔴 Swollen hands should be reported because they often signal worsening endothelial dysfunction and possible complications, such as hypertension or progression to eclampsia.

Headache

🔴 Persistent or severe headache is a neurological warning sign of worsening preeclampsia and may be due to cerebral edema or vasospasm.

🔴 It is often refractory to usual pain relief methods, distinguishing it from common pregnancy-related headaches.

🔴 This symptom suggests risk for seizure activity and must be reported to initiate timely assessment and possibly magnesium sulfate therapy.

Blurred vision

🔴 Visual disturbances such as blurred vision, seeing spots, or double vision result from retinal vasospasm or cerebral involvement.

🔴 These findings are considered neurological manifestations and may precede or accompany seizures (eclampsia).

🔴 Prompt recognition is crucial, as it reflects central nervous system irritation requiring immediate medical evaluation and intervention.

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Answer 8

Correct Answers:

Encourage the parents to allow the child to continue attending swimming lessons With supervision.

Rationale :

Swimming is a low-resistance activity that promotes joint mobility and cardiovascular health in Duchenne muscular dystrophy (DMD).
Continued participation promotes normalcy, emotional well-being, and physical function.
Supervised activity reduces risk of injury or fatigue while promoting independence.
Avoiding overprotection helps foster self-esteem and social development.
Supporting preferred activities within safe limits is aligned with family-centered care.

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Answer 9

Correct Answers:

Reduce intestinal activity.

Rationale :

⏺️Activity restriction reduces mechanical stress and peristalsis in the inflamed bowel.

⏺️ In Crohn’s disease, excessive movement can exacerbate inflammation and pain.

⏺️Conserving energy allows the body to focus on healing and nutrient absorption.

⏺️Decreased bowel stimulation helps prevent diarrhea, cramping, and complications.

⏺️This is part of a conservative management approach during flare-ups.

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Answer 10

Correct Answers:

Wear protective goggles while performing the procedure.

Rationale :

🧤 Suctioning can lead to aerosolized secretions or splashes, posing infection risk.

🧤 Goggles protect mucous membranes from saliva or oral pathogens.

🧤 ALS clients have compromised control over secretions, increasing exposure risks.

🧤 Use of PPE is mandated under standard and droplet precautions for drooling clients.

🧤 Eye protection supports infection prevention and personal safety.

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RN-HESI Exit~2023 Exam 4

No.

2 :
In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority?

3 :
The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the client?

4 :
A client experiencing withdrawal from the benzodiazepine alprazolam is demonstrating severe agitation and tremors. Which is the best initial nursing action?

6 :
A client with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. Which schedule should the nurse implement to assess the client's blood pressure after this procedure?

7 :
The nurse is teaching a primigravida about preeclampsia. What finding(s) are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.

8 :
The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?

9 :
Restricted activity is prescribed for a client with Crohn's disease.The nurse should explain that the primary purpose of the activity restriction is to obtain which outcome?

10 :
The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

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RN-HESI Exit~2023 Exam 4

No.

2 : In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority?

3 : The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the client?

4 : A client experiencing withdrawal from the benzodiazepine alprazolam is demonstrating severe agitation and tremors. Which is the best initial nursing action?

6 : A client with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. Which schedule should the nurse implement to assess the client's blood pressure after this procedure?

7 : The nurse is teaching a primigravida about preeclampsia. What finding(s) are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.

8 : The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?

9 : Restricted activity is prescribed for a client with Crohn's disease.The nurse should explain that the primary purpose of the activity restriction is to obtain which outcome?

10 : The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

2 :
In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority?

3 :
The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the client?

4 :
A client experiencing withdrawal from the benzodiazepine alprazolam is demonstrating severe agitation and tremors. Which is the best initial nursing action?

6 :
A client with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. Which schedule should the nurse implement to assess the client's blood pressure after this procedure?

7 :
The nurse is teaching a primigravida about preeclampsia. What finding(s) are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.

8 :
The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?

9 :
Restricted activity is prescribed for a client with Crohn's disease.The nurse should explain that the primary purpose of the activity restriction is to obtain which outcome?

10 :
The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?