HESI RN Exit V2 *|Complete Questions with Correct Answers

HESI RN Exit V2 *|Complete Questions with Correct Answers The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns that the client has a current blood glucose level of 720 mg/dL. When assessing the client, what is the priority? A. Assess for signs of fluid volume deficit B. Observe wound drainage characteristics C. Measure the level of acute pain D. Determine when the client last ate A. Assess for signs of fluid volume deficit A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and dull gnawing pain that is relieved when he eats. Which is the best response by the nurse? A. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer B. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food C. Instruct the client that these mild symptoms can generally be controlled with changes in his diet D. Advise the client that he needs to seek immediate medical evaluation and treatment of these symptoms A. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hr IV. One hour after admission to the unit, the nurse notes 300mL of blood in the suction canister, the client's heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the findings to the surgeon, which action should the nurse implement first? A. Measure and document the client's urinary output B. Request the client's reserved unit of packed red blood cells C. Prepare for placement of a central venous catheter D. Increase the infusion rate of Lactated Ringer's solution D. Increase the infusion rate of Lactated Ringer's solution A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the heparin solution as 18 units/kg/hour. The available solution is Heparin Sodium 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program the infusion pump to deliver how many mL/hour? -1st: calculate the weight = 220/2.2= 100kg -Then calculate total dose in units = 18units x 100kg = 1800 units/hr - 25000 units - in 250 1800 units ---in X ml x = 1800 x 250/25000 =18 mL/hr An adult male who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse notes that the suction control chamber is bubbling at the -10cm H2O mark, which fluctuation in the water seal, and over the past hour 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? A. Add sterile water to the suction control chamber