HESI 799 RN Exit Exam Quizlet

Questions 73

HESI RN

HESI RN Test Bank

HESI 799 RN Exit Exam Quizlet Questions

Question 1 of 5

The nurse is administering an IV medication to a client with a history of anaphylaxis. Which intervention is most important for the nurse to implement?

Correct Answer: B

Rationale: Keeping emergency resuscitation equipment at the bedside is crucial in case the client experiences anaphylaxis during the infusion. While staying with the client throughout the infusion (Choice A) is important, having immediate access to emergency equipment takes priority in this situation. Obtaining the client's allergy history (Choice C) and asking about past allergic reactions to medications (Choice D) are relevant but do not address the immediate need for emergency intervention in case of anaphylaxis.

Question 2 of 5

The nurse reviews the laboratory findings of a client with an open fracture of the tibia. The white blood cell (WBC) count and erythrocyte sedimentation rate (ESR) are elevated. Before reporting this information to the healthcare provider, what assessment should the nurse obtain?

Correct Answer: A

Rationale: The correct answer is A: Appearance of wound. Elevated WBC and ESR levels suggest a possible infection in the client with an open fracture. Assessing the wound's appearance is crucial to evaluate for signs of infection, such as redness, warmth, swelling, or drainage. By assessing the wound first, the nurse can provide important information to the healthcare provider regarding the potential infection, which may require immediate intervention. Choices B, C, and D are important assessments in caring for a client with an open fracture; however, in this scenario, the priority is to assess the wound for signs of infection due to the elevated WBC and ESR levels.

Question 3 of 5

A client with heart failure is prescribed furosemide (Lasix). Which assessment finding requires immediate intervention?

Correct Answer: C

Rationale: The correct answer is C. Crackles in the lungs indicate fluid overload, a common issue in heart failure patients. Immediate intervention is necessary to prevent worsening heart failure symptoms and potential complications. A heart rate of 60 beats per minute and a blood pressure of 100/60 mmHg are within normal ranges for many individuals and do not typically require immediate intervention in this context. The presence of a new murmur may be important to monitor but is not the priority when crackles in the lungs suggest fluid overload.

Question 4 of 5

The nurse is reinforcing home care instructions with a client who is being discharged following a transurethral resection of the prostate (TURP). Which intervention is most important for the nurse to include in the client teaching?

Correct Answer: B

Rationale: Reporting fresh blood in the urine is crucial as it may indicate postoperative complications requiring immediate attention. This symptom can be a sign of bleeding, infection, or other issues that need prompt medical evaluation. Avoiding strenuous activity for 6 weeks is important but not as urgent as reporting fresh blood. Taking acetaminophen for a fever over 101�F is relevant but addressing fresh blood in the urine takes precedence. Consuming an adequate amount of water daily is beneficial but not as critical as recognizing and reporting signs of potential complications.

Question 5 of 5

During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?

Correct Answer: A

Rationale: The correct answer is A: Respiratory apnea of 30 seconds. Respiratory apnea indicates a cessation of breathing, which is a life-threatening emergency requiring immediate intervention. Priority should be given to assessing and managing airway, breathing, and circulation. Option B, oxygen saturation rate of 88%, can indicate hypoxemia, but addressing the lack of breathing takes precedence. Option C, eight premature ventricular beats every minute, and option D, a disconnected monitor signal, are important but do not pose an immediate threat to the client's life compared to respiratory apnea.

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