HESI RN
HESI 799 RN Exit Exam Questions
Question 1 of 5
Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to the healthcare provider for evaluation of thyroid functioning?
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.
Question 2 of 5
The nurse is caring for a client with a tracheostomy who has thick, tenacious secretions. Which assessment finding requires immediate intervention?
Correct Answer: C
Rationale: Mucous plugging of the tracheostomy tube is the most concerning assessment finding in a client with a tracheostomy. It can lead to airway obstruction, which requires immediate intervention to ensure the client's airway remains patent. Crepitus around the tracheostomy site may indicate subcutaneous emphysema but is not as urgent as a blocked airway. A dry and cracked tracheostomy site may indicate poor skin integrity but does not pose an immediate threat to the client's airway. Yellowing of the skin around the tracheostomy site could suggest a localized infection, but it is not as critical as a potential airway obstruction caused by mucous plugging.
Question 3 of 5
The nurse is caring for a client with a tracheostomy who has thick, tenacious secretions. Which intervention should the nurse implement first?
Correct Answer: C
Rationale: Increasing humidity in the client's room is the first priority in managing thick, tenacious secretions in a client with a tracheostomy to facilitate airway clearance. This intervention helps to moisten secretions, making them easier to clear. Encouraging fluid intake (Choice A) can be beneficial, but increasing humidity should be addressed first. Administering a mucolytic agent (Choice B) and performing deep suctioning (Choice D) are interventions that can be considered after addressing humidity if necessary, but they are not the initial priority.
Question 4 of 5
The nurse is preparing to administer an intramuscular injection to a client with muscle wasting in the gluteal region. What is the most appropriate site for the injection?
Correct Answer: D
Rationale: The vastus lateralis site is the most appropriate for an IM injection in a client with muscle wasting in the gluteal region. Administering the injection in the vastus lateralis ensures effective medication delivery due to muscle wasting in the gluteal region, preventing potential complications associated with the dorsogluteal or ventrogluteal sites, which may not be suitable in this specific client case. The deltoid site is mainly used for smaller volumes of medication and may not be ideal for this scenario.
Question 5 of 5
The nurse is caring for a client with end-stage renal disease (ESRD) who is scheduled for hemodialysis. Which clinical finding is most concerning?
Correct Answer: C
Rationale: The correct answer is C. A fever of 100.4�F is most concerning in a client with ESRD scheduled for hemodialysis because it may indicate an underlying infection that requires immediate attention. Elevated body temperature can be a sign of systemic infection, which can quickly worsen in individuals with compromised renal function. Monitoring for infection is crucial in ESRD patients to prevent complications. Choices A, B, and D are not as immediately concerning in this context. While variations in blood pressure, heart rate, and respiratory rate should be monitored, they are not as indicative of a potentially severe issue as an unexplained fever in this scenario.
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