HESI 799 RN Exit Exam

Questions 72

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HESI 799 RN Exit Exam Questions

Question 1 of 5

A client with a head injury is receiving mechanical ventilation. Which finding indicates to the nurse that the client may be experiencing increased intracranial pressure (ICP)?

Correct Answer: D

Rationale: In a client with increased intracranial pressure (ICP), the body's compensatory mechanisms lead to an elevation in blood pressure and a widening pulse pressure. This occurs due to the body's attempt to maintain cerebral perfusion. Therefore, elevated blood pressure and widening pulse pressure are classic signs of increased ICP and necessitate immediate attention. Choices A, B, and C are incorrect because a widening pulse pressure, sudden drop in heart rate, or decreased urine output are not specific indicators of increased ICP.

Question 2 of 5

While auscultating a client's heart sounds, which description should the nurse use to document a swishing sound related to blood turbulence or valvular defect?

Correct Answer: C

Rationale: The correct answer is 'C: Murmur.' A murmur is auscultated as a swishing sound associated with blood turbulence caused by the heart or a valvular defect. Choices 'A: S1 S2' and 'B: S1 S2 S3' refer to normal heart sounds, specifically the closure of heart valves. 'D: Pericardial friction rub' is a dry, rubbing or grating sound caused by inflammation of the pericardial sac and is not associated with blood flow or valvular issues.

Question 3 of 5

A male client is prescribed clozapine (Clozaril), an antipsychotic medication, for the management of schizophrenia. Which client history should the nurse report to the healthcare provider before administering the first dose of this medication?

Correct Answer: B

Rationale: The correct answer is B: History of cardiac arrhythmia. Clozapine can lead to severe cardiovascular problems, making it crucial to report any history of cardiac arrhythmia to the healthcare provider before administering the medication. Choices A, C, and D are less concerning in this context as they are not directly associated with potential serious complications related to clozapine use.

Question 4 of 5

A client with a history of congestive heart failure is admitted with shortness of breath. Which nursing intervention should the nurse implement first?

Correct Answer: A

Rationale: The correct answer is to elevate the head of the bed. Elevating the head of the bed is crucial in improving oxygenation in clients with congestive heart failure and shortness of breath by reducing venous return to the heart and decreasing fluid overload in the lungs. This intervention helps to alleviate the client's breathing difficulty. Administering diuretic therapy (Choice B) may be necessary but is not the initial priority. Monitoring oxygen saturation (Choice C) is important but should come after ensuring proper positioning. Assessing the client's level of consciousness (Choice D) is essential but is not the first intervention needed for a client experiencing respiratory distress.

Question 5 of 5

A client with a postoperative wound that eviscerated yesterday has an elevated temperature. What is the most important intervention for the nurse to implement?

Correct Answer: B

Rationale: Obtaining a wound swab for culture and sensitivity is the most important intervention in this situation. It helps identify the presence of infection in the postoperative wound that could be causing the elevated temperature. By obtaining a wound swab, healthcare providers can determine the appropriate treatment needed to address any infection. Initiating contact isolation (Choice A) may be necessary in certain situations but is not the priority in this case. Assessing temperature (Choice C) is important but does not directly address the underlying cause of the elevated temperature. Using alcohol-based solutions for hand hygiene (Choice D) is a standard practice for infection control but is not the most crucial intervention in this scenario.

Similar Questions

A client with a postoperative wound that eviscerated yesterday has an elevated temperature. What is the most important intervention for the nurse to implement?
A client with a head injury is receiving mechanical ventilation. Which finding indicates to the nurse that the client may be experiencing increased intracranial pressure (ICP)?
The nurse is assessing a female client's blood pressure because she reported feeling dizzy. The blood pressure cuff is inflated to 140 mm Hg and as soon as the cuff is deflated a Korotkoff sound is heard. Which intervention should the nurse implement next?
The nurse is preparing to administer an enema to a client with severe constipation. Which position is most appropriate for the client?
The nurse needs to add a medication to a liter of 5% Dextrose in Water (D5W) that is already infusing into a client. At what location should the nurse inject the medication?

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