HESI RN Exit Exam 2024 Quizlet Capstone

Correct Answer: C

Rationale: All of the above findings should be reported to the healthcare provider for prompt evaluation and treatment. Swollen lymph nodes in the groin indicate regional lymphatic involvement, a core body temperature of 100.5�F suggests a mild fever response, and an elevated white blood cell count indicates an ongoing infection process. These findings collectively point towards the spread of infection and require immediate attention to prevent further complications.

Correct Answer: C

Rationale: When a pediatric client is taking propranolol, the nurse should instruct the parents to report signs of overdose, including bradycardia. Propranolol is a beta-blocker that can lead to dangerously slow heart rate as a sign of overdose. While increased respiratory rate, seizures, and irritability may occur in some cases, bradycardia is the most critical symptom indicating an overdose of this medication.

Correct Answer: B

Rationale: The correct teaching for a client prescribed metformin includes monitoring renal function regularly due to the risk of lactic acidosis, especially in clients with impaired kidney function. While taking metformin with meals can reduce gastrointestinal upset, it is not the highest priority teaching point. Avoiding alcohol is generally recommended but not the most critical teaching point in this scenario. Checking blood glucose levels regularly is important for diabetes management but not specifically related to metformin use.

Correct Answer: D

Rationale: In this scenario, the patient's presentation with periorbital bruising and bloody ear drainage suggests a basilar skull fracture. Projectile vomiting, as described in choice D, is concerning for increased intracranial pressure due to the skull fracture. This finding warrants immediate intervention to prevent further neurological compromise. Choices A, B, and C are not the priority in this situation. Rebound abdominal tenderness (choice A) is indicative of intra-abdominal injury but is not as urgent as managing potential intracranial issues. Diminished breath sounds (choice B) and rib pain with deep inspiration (choice C) may suggest underlying chest injuries, which need attention but are not as immediately life-threatening as increased intracranial pressure.

Correct Answer: A

Rationale: Seeing halos around lights is a classic symptom of digoxin toxicity. The nurse should assess the client's digoxin level to determine if the dose needs to be adjusted or if the medication should be held. Increasing fluid intake or checking blood pressure would not directly address the symptom of halos around lights. Administering a dose of potassium is not indicated without knowing the digoxin level and could potentially worsen the toxicity.