HESI 799 RN Exit Exam

Questions 72

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HESI 799 RN Exit Exam Questions

Question 1 of 5

Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which action should the nurse implement?

Correct Answer: A

Rationale: After an open reduction of the tibia, bleeding on the cast can be a concern. Outlining the area with ink and monitoring it every 15 minutes is the appropriate action to assess if the bleeding is worsening, indicating the need for further intervention. This action allows for close observation without disturbing the cast. Choice B is incorrect because while notifying the healthcare provider is important, immediate action is not always necessary if the bleeding is not severe. Choice C is incorrect because applying a new cast is not the standard intervention for bleeding on a cast. Choice D is incorrect because elevating the limb may not address the underlying cause of bleeding and may not be the most appropriate action at this time.

Question 2 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 3 of 5

When administering ceftriaxone sodium (Rocephin) intravenously to a client, which finding requires the most immediate intervention by the nurse?

Correct Answer: A

Rationale: The correct answer is A: Stridor. Stridor indicates bronchospasm, a serious reaction that can compromise the client's airway. Immediate intervention is crucial to prevent further respiratory distress. Nausea, headache, and pruritus are potential side effects of ceftriaxone but are not as immediately life-threatening as airway compromise indicated by stridor.

Question 4 of 5

A nurse plans to call the healthcare provider to report an 0600 serum potassium level of 2 mEq/L or mmol/L (SI), but the charge nurse tells the nurse that the healthcare provider does not like to receive early morning calls and will make rounds later in the morning. What action should the nurse take?

Correct Answer: A

Rationale: A nurse should contact the healthcare provider immediately to report a critically low potassium level of 2 mEq/L. Potassium levels below the normal range can lead to life-threatening complications such as cardiac arrhythmias. Prompt notification is essential to ensure timely intervention and prevent harm to the patient. Option B is incorrect as delaying reporting such a critical value can jeopardize patient safety. Option C is not the priority in this situation; the focus should be on patient care. Option D is dangerous and inappropriate as administering a potassium supplement without healthcare provider's guidance can be harmful, especially with a critically low level.

Question 5 of 5

Which assessment finding indicates to the nurse a client's readiness for pulmonary function tests?

Correct Answer: A

Rationale: The correct answer is A: 'Expresses an understanding of the procedure.' This choice indicates that the client is mentally prepared for the pulmonary function tests, as understanding the procedure shows readiness and cooperation. Choices B, C, and D are incorrect. Choice B, 'NPO for 6 hrs,' pertains to fasting status and is not directly related to readiness for the test. Choice C, 'No known drug allergies,' is important information but does not specifically indicate readiness for pulmonary function tests. Choice D, 'Intravenous access intact,' is related to vascular access and not a direct indicator of readiness for the pulmonary function tests.

Similar Questions

Which assessment finding indicates to the nurse a client's readiness for pulmonary function tests?
Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which action should the nurse implement?
A client with type 1 diabetes is admitted with hypoglycemia. Which intervention should the nurse implement first?
The nurse is preparing to administer an enema to a client with severe constipation. Which position is most appropriate for the client?
The nurse is caring for a client with a tracheostomy who has thick, tenacious secretions. Which intervention should the nurse implement first?

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