Question

A nurse is monitoring a client receiving a blood transfusion. Which of the following actions should the nurse take first?

Answer 1

Correct Answers:

Stop the blood transfusion.

Rationale :

🔷 Stopping the transfusion is the priority when a transfusion reaction is suspected, as it prevents further infusion of potentially harmful or incompatible blood products.

🔷 Immediate cessation minimizes the risk of complications like hemolysis or anaphylaxis, which can quickly become life-threatening.

🔷 This action allows time for the nurse to assess the client's condition and notify the provider for further evaluation.

🔷 It also ensures that the reaction can be properly documented and investigated, including sending the blood bag and tubing to the lab.

🔷 Rapid intervention is essential to maintain patient safety and begin supportive treatment if needed.

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Answer 2

Correct Answers:

Cefazolin 1 gram IV every 6 hours.

Rationale :

🔸 Prophylactic antibiotic administration is time-sensitive, especially postoperatively, to prevent surgical site infections.

🔸 Cefazolin is typically given within a narrow window after surgery to maintain therapeutic blood levels and reduce bacterial colonization.

🔸 Infections can increase morbidity and length of stay, making early antibiotic intervention critical.

🔸 This action takes priority over non-urgent tasks like dietary advancement or labs scheduled for the next day.

🔸 Immediate interventions that prevent complications must be implemented first post-PACU.

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Answer 3

Correct Answers:

The client is competent to sign the consent without impairment of judgment.
The client voluntarily grants permission for the procedure to be done.

Rationale :

🟠 The nurse's signature legally confirms that the client signed the consent while mentally competent, not impaired by drugs or confusion.

🟠 It also affirms that the client willingly and voluntarily gave consent, which is a critical element of informed consent.

🟠 The role of the nurse is as a witness, not to verify the client’s understanding of the surgery details—that responsibility falls to the provider.

🟠 By signing, the nurse ensures ethical and legal standards of autonomy and voluntariness were upheld.

🟠 This protects both the client and the institution legally.

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Answer 4

Correct Answers:

A client with a positive Mantoux and sputum cultures results positive for acid-fast bacillus (AFB).

Rationale :

🔶 AFB-positive tuberculosis (TB) is spread via airborne particles, requiring strict airborne isolation in a negative airflow room.

🔶 Particulate respirator masks (like N95) are essential to protect staff from inhaling Mycobacterium tuberculosis.

🔶 This client poses the highest transmission risk and must be managed with both airborne and standard precautions.

🔶 Failure to isolate appropriately can result in rapid nosocomial spread of TB.

🔶 TB is one of the few conditions mandating airborne precautions at all times during hospitalization.

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Answer 5

Correct Answers:

Assess the serum potassium level every 4 hours.

Rationale :

🔵 Regular insulin drives potassium into the cells, rapidly lowering serum potassium, which can result in hypokalemia.

🔵 Monitoring serum potassium ensures early detection of dangerous shifts, such as cardiac arrhythmias due to low potassium.

🔵 This is especially critical in patients already presenting with hyperkalemia (K⁺ of 6.0 mEq/L).

🔵 Insulin therapy for hyperkalemia is temporary, so monitoring helps guide further management.

🔵 Changes in potassium can quickly become fatal if not monitored and corrected in time.

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Answer 6

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available

Rationale :

🟣 First, objective documentation (date and time) creates a factual record of the incident. 🟣 Second, addressing underlying causes by adjusting the schedule helps support behavior change. 🟣 Finally, evaluating for improvement measures the success of the intervention plan. 🟣 Following a progressive disciplinary model aligns with professional accountability standards. 🟣 This structured response promotes fairness and corrective action.

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Answer 7

Correct Answers:

Brain damage with CP is not progressive but does have a variable course.

Rationale :

🟣 Brain damage with CP is non-progressive—it does not worsen over time.

🟣 Effects may appear to worsen as developmental expectations increase.

🟣 Symptoms vary widely depending on lesion location and severity.

🟣 Provides hope for maintaining or improving function through therapy.

🟣 Static nature of the condition distinguishes CP from degenerative disorders.

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Answer 8

Correct Answers:

Ask the client about individual care preferences.

Rationale :

💠 Directly asking the client ensures care is respectful of unique religious practices.

💠 Promotes individualized, culturally competent care.

💠 Encourages trust and compliance in the healthcare relationship.

💠 Avoids assumptions or stereotyping based on general religious information.

💠 Demonstrates patient-centered communication and holistic nursing practice.

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Answer 9

Correct Answers:

1000

Rationale :

✴️ 500 mL ÷ 30 min

16.67 mL/min

✴️Volume ÷ time × 60.

✴️ 16.67 × 60 min

1000 mL/hr

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Answer 10

Correct Answers:

Participation of community leaders in planning the program.

Rationale :

💚 Community leaders offer cultural insights specific to African-American women.

💚 Builds trust and enhances program participation.

💚 Leverages local influence to drive health outcomes.

💚 Supports sustainable, targeted interventions.

💚 Increases effectiveness of outreach efforts.

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HESI-RN College Exit~2024

No.

1 :
A nurse is monitoring a client receiving a blood transfusion. Which of the following actions should the nurse take first?

2 :
A nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

3 :
After the nurse witnesses a preoperative client signing the surgical consent form, the nurse signs the form as a witness. Which is the legal implication of the nurse's signature on the client's surgical consent form? Select all that apply.

4 :
The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

5 :
The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

6 :
An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

7 :
The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

8 :
A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

9 :
The healthcare provider (HCP) prescribes 0.99% normal saline 500 mL IV bolus to be infused over 30 minutes. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only) .

10 :
The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

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HESI-RN College Exit~2024

No.

1 : A nurse is monitoring a client receiving a blood transfusion. Which of the following actions should the nurse take first?

2 : A nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

3 : After the nurse witnesses a preoperative client signing the surgical consent form, the nurse signs the form as a witness. Which is the legal implication of the nurse's signature on the client's surgical consent form? Select all that apply.

4 : The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

6 : An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

7 : The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

8 : A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

9 : The healthcare provider (HCP) prescribes 0.99% normal saline 500 mL IV bolus to be infused over 30 minutes. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only) .

10 : The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

1 :
A nurse is monitoring a client receiving a blood transfusion. Which of the following actions should the nurse take first?

2 :
A nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

3 :
After the nurse witnesses a preoperative client signing the surgical consent form, the nurse signs the form as a witness. Which is the legal implication of the nurse's signature on the client's surgical consent form? Select all that apply.

4 :
The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

6 :
An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

7 :
The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

8 :
A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

9 :
The healthcare provider (HCP) prescribes 0.99% normal saline 500 mL IV bolus to be infused over 30 minutes. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only) .

10 :
The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?