HESI 799 RN Exit Exam

Correct Answer: A

Rationale: If a Korotkoff sound is heard immediately upon deflation, it may indicate an inaccurate reading. Waiting and palpating the systolic pressure can help confirm the accuracy of the measurement. Choice A is the correct intervention because it allows the nurse to ensure the accuracy of the blood pressure reading. Choice B is incorrect as increasing the inflation pressure is not necessary in this situation. Choice C is also incorrect as switching to a larger cuff is not warranted based on the information provided. Choice D is incorrect because documenting the finding as normal without further verification could lead to inaccurate information.

Correct Answer: A

Rationale: The correct answer is A: Cold sensitivity. Cold sensitivity is a common symptom of hypothyroidism, a condition that affects the thyroid gland's ability to produce enough hormones. As a postmenopausal woman presents with cold sensitivity, it may indicate an underlying thyroid issue. Hot flashes (choice B) are more commonly associated with menopause than thyroid dysfunction. While weight gain (choice C) and dry skin (choice D) can also be symptoms of thyroid disorders, cold sensitivity is more specific and indicative of hypothyroidism, requiring prompt evaluation by a healthcare provider.

Correct Answer: C

Rationale: The correct answer is C. The presence of a new murmur in a client with heart failure receiving digoxin and furosemide is concerning as it may indicate valvular problems or other complications that require immediate intervention. A heart rate of 60 beats per minute and an apical pulse of 58 beats per minute are within normal limits for a client with heart failure on these medications. A blood pressure of 100/60 mmHg, while slightly low, may be expected due to the diuretic effect of furosemide and may not require immediate intervention unless the client is symptomatic.

Correct Answer: A

Rationale: The correct first intervention for a male client with a bowel obstruction and intractable vomiting is to infuse 0.9% sodium chloride 500 ml bolus. This intervention is crucial to address the risk of hypovolemia due to excessive vomiting. Administering intravenous fluids will help prevent dehydration, maintain blood pressure, and stabilize the client's condition. Choice B, administering an antiemetic intravenously, may not be effective as the client has already been unresponsive to antiemetics orally. Choice C, inserting a nasogastric tube, may be necessary but is not the priority in this situation. Choice D, preparing the client for surgery, should only be considered after stabilizing the client's fluid and electrolyte balance.

Correct Answer: A

Rationale: Playing a board game with the client and initiating a conversation about stressors is the best choice to establish rapport and achieve the therapeutic goal of helping the client verbalize ways to cope with stress. Board games provide a relaxed and non-threatening environment, allowing the client to feel more comfortable and open up about their stressors. Choice B, conducting a formal therapy session, might be too structured and intimidating for the client, hindering open communication. Choice C, asking the client to write down their feelings, lacks the interactive and engaging aspect that a board game provides. Choice D, having a group discussion about stress management, may not be as effective initially as one-on-one interaction to build trust and rapport with the client.