A female client with acute respiratory distress syndrome (ARDS) is sedated and on a ventilator with 50% FIO2. What assessment finding warrants immediate intervention?- Skildor

Question 1 of 5

A female client with acute respiratory distress syndrome (ARDS) is sedated and on a ventilator with 50% FIO2. What assessment finding warrants immediate intervention?

A. Assess the client's lung sounds bilaterally. B. Diminished left lower lobe sounds. C. Monitor ventilator settings for changes in oxygen levels. D. Increased sputum production and shortness of breath.

Correct Answer: B

Rationale: Diminished breath sounds in a sedated client with ARDS and on a ventilator indicate collapsed alveoli, which requires immediate intervention, such as chest tube insertion, to prevent further lung damage.

Question 2 of 5

A client is receiving a blood transfusion and reports feeling chilled and short of breath. What is the nurse's priority action?

A. Stop the transfusion and notify the healthcare provider. B. Administer an antihistamine as prescribed. C. Administer a dose of acetaminophen. D. Administer a PRN dose of diphenhydramine.

Correct Answer: A

Rationale: Stopping the transfusion prevents further reactions, and notifying the healthcare provider ensures timely intervention.

Question 3 of 5

An older client is admitted to the intensive care unit unconscious after several days of vomiting and diarrhea. The nurse inserts a urinary catheter and observes dark amber urine output. Which intervention should the nurse implement first?

A. Begin dopamine infusion at 2 mcg/kg/minute. B. Begin potassium chloride 10 mEq over 1 hour. C. Give a bolus of 0.9% sodium chloride 1000 mL over 30 minutes. D. Administer promethazine 25 mg IV push.

Correct Answer: C

Rationale: A fluid bolus is the first step in stabilizing a client with hypovolemic symptoms.

Question 4 of 5

While changing a client's chest tube dressing, the nurse notes a cracking sensation when gentle pressure is applied to the skin at the insertion site. What should the nurse do next?

A. Apply a pressure dressing at the chest tube site. B. Administer an oral antihistamine per PRN order. C. Assess the client for allergies to topical cleaning agents. D. Measure the area of crackling and swelling.

Correct Answer: D

Rationale: Measuring the area of swelling and crackling helps monitor subcutaneous emphysema progression.

Question 5 of 5

The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instruction should the nurse provide the UAP who is working with the nurse?

A. Encourage the client to increase fluid intake B. Document the absence of reaction C. Notify the nurse if the client develops a fever D. Continue to measure the client's vital signs every thirty minutes until the transfusion is complete

Correct Answer: D

Rationale: Monitoring vital signs throughout a transfusion is critical, as reactions can occur later in the process. The UAP should continue to check vital signs regularly to ensure that any delayed reaction is promptly detected.

HESI RN Exit Exam Capstone

Skildor

HESI RN

HESI RN

HESI RN Exit Exam Capstone Questions

Question 1 of 5

Question 2 of 5

Question 3 of 5

Question 4 of 5

Question 5 of 5

Similar Questions

Join Our Community Today!