HESI Exit Exam Version 4 100 Questions and Correct Answers 2022
If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous
... [Show More] membranes, flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child has a sodium concentration of 156 mEq/L. What physiologic mechanism contributes to this finding?
Insensible loss of body fluids contributes to the hemoconcentration of serum solutes.
Rationale: Fever causes insensible fluid loss, which contribute to fluid volume and results in hemoconcentration of sodium (serum sodium greater than 150 mEq/L). Dehydration, which is manifested by dry, sticky mucous membranes, and flushed skin, is often managed by replacing lost fluids and electrolytes with IV fluids that contain varying concentration of sodium chloride. Although other options are consistent with fluid volume deficit, the physiologic response of hypernatremia is explained by hem concentration.
During a Woman's Health fair, which assignment is the best for the Practical Nurse (PN) who is working with a register nurse (RN)
Prepare a woman for a bone density screening.
Rationale: A bone density screening is a fast, noninvasive screening test for osteoporosis that can be explained by the PN. There is no additional preparation needed (A) required a high level of communication skill to provide teaching and address the client's fear. (B) Requires a higher level of client teaching skill than responding to one client. (D) Requires higher level of knowledge and expertise to provide needed teaching regarding this complex topic.
An adult client present to the clinic with large draining ulcers on both lower legs that are characteristics of Kaposi's sarcoma lesions. The client is accompanied by two family member. Which action should the nurse take?
Send family to the waiting area while the client's history is taking.
Rationale: To protect the client privacy, the family member should be asked to wait outside while the client's history is take. Gloves should be worn when touching the client's body fluids if the client is HIV positive and these lesion are actually Kaposi sarcoma lesion. HIV testing cannot legally be done without the client explicit permission. A further assessment can be implemented after the family left the room.
An adult client is exhibit the maniac stage of bipolar disorder is admitted to the psychiatric unit. The client has lost 10 pounds in the last two weeks and has no bathed in a week "I'm trying to start a new business and "I'm too busy to eat". The client is oriented to time, place, person but not situation. Which nursing problem has the greatest priority?
Imbalance nutrition.
Rationale: The client's nutritional status has the highest priority at this time, and finger foods are often provided, so the client who is on the maniac phase of bipolar disease can receive adequate nutrition. Other options are nursing problems that should also be addresses with the client's plan of care, but at this stage in the client's treatment, adequate nutrition is a priority. [Show Less]