HESI RN Exit Exam

Questions 72

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HESI RN Exit Exam Questions

Question 1 of 5

A client is admitted with a diagnosis of sepsis. Which assessment finding is most concerning to the nurse?

Correct Answer: D

Rationale: A blood pressure of 90/60 mmHg in a client with sepsis is concerning for septic shock, a life-threatening condition that requires immediate intervention. Hypotension is a severe manifestation of sepsis that can lead to poor tissue perfusion and organ failure. While the other assessment findings such as an elevated temperature, increased heart rate, and respiratory rate are also common in sepsis, hypotension is particularly alarming as it indicates a critical state of shock and necessitates urgent medical attention.

Question 2 of 5

While caring for a toddler receiving oxygen (02) via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

Correct Answer: D

Rationale: A water-soluble lubricant is safe to use in conjunction with oxygen therapy, unlike petroleum jelly which is flammable.

Question 3 of 5

While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

Correct Answer: A

Rationale: The correct answer is A: 'Elevated blood pressure must be anticipated and identified quickly.' Acute glomerulonephritis can lead to significant hypertension, making it crucial to monitor blood pressure frequently to promptly identify any elevation. Choice B is incorrect because while monitoring can help assess medication effectiveness, the primary reason for frequent blood pressure checks in this case is to detect elevated blood pressure. Choice C is incorrect as not all hospitalized children require such frequent blood pressure monitoring. Choice D is incorrect as the primary reason for monitoring blood pressure is to detect hypertension, rather than solely focusing on potential kidney damage.

Question 4 of 5

During orientation, a newly hired nurse demonstrates suctioning of a tracheostomy in a skills class. After the demonstration, the supervising nurse expresses concern that the demonstrated procedure increased the client's risk for which problem?

Correct Answer: A

Rationale: The correct answer is A: Infection. Improper suctioning techniques can introduce pathogens, increasing the risk of infection. Choice B, Hypoxia, is incorrect as it is more related to inadequate oxygen supply. Choice C, Bleeding, is not typically associated with suctioning a tracheostomy unless done too aggressively. Choice D, Bronchospasm, is not directly linked to suctioning but may occur due to other triggers in patients with sensitive airways.

Question 5 of 5

A client with severe COPD is receiving oxygen therapy at 2 liters per minute via nasal cannula. The client's oxygen saturation level drops to 88% during ambulation. What action should the nurse take first?

Correct Answer: C

Rationale: In this scenario, the client's oxygen saturation level dropping during ambulation indicates an inadequate oxygen supply. The first action the nurse should take is to discontinue ambulation and return the client to bed. This helps stabilize the oxygen level by reducing the oxygen demand placed on the client during physical activity. Increasing the oxygen flow rate without addressing the underlying issue of oxygen saturation dropping may not be effective. Instructing the client to rest is not enough to address the immediate need for stabilization of oxygen levels. Encouraging the client to breathe more deeply may not be sufficient to overcome the oxygen saturation drop caused by inadequate oxygen supply during ambulation.

Similar Questions

A client with severe COPD is receiving oxygen therapy at 2 liters per minute via nasal cannula. The client's oxygen saturation level drops to 88% during ambulation. What action should the nurse take first?
Which assessment is most important for the nurse to include in the daily plan of care for a client with a burned extremity?
While assisting a male client with muscular dystrophy (MD) to the bathroom, the nurse observes that he is awkward and clumsy. When he expresses his frustration and complains of hip discomfort, which intervention should the nurse implement?
The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin shock. What is the most immediate intervention by the nurse?
A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which clinical finding is most concerning to the nurse?

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