HESI RN Exit Exam 2024 Quizlet Capstone

Correct Answer: B

Rationale: The correct answer is B. Pale mucous membranes, such as those of the eyelids and lips, are a classic sign of anemia in infants. Anemia leads to decreased oxygen-carrying capacity, resulting in tissue hypoxia, which can manifest as pale mucosa. Choice A, a hemoglobin level of 12 g/dL, is within the normal range for a 10-month-old infant and would not necessarily indicate anemia. Choice C, hypoactivity, is a non-specific finding and can be present in various conditions, not specifically anemia. Choice D, a heart rate between 140 to 160, is within the normal range for an infant and is not a specific finding associated with anemia.

Correct Answer: A

Rationale: The correct answer is to administer bronchodilators as prescribed. During an acute asthma attack, the priority is to open the airways quickly to help the client breathe more easily. Oxygen may be needed but bronchodilators take precedence as they directly target bronchoconstriction. Chest physiotherapy is not indicated in the acute phase of asthma and may exacerbate the condition. While emotional support is important, addressing the airway obstruction takes precedence in this situation.

Correct Answer: C

Rationale: Assisting the client to stand by the side of the bed to void is the most appropriate action in this situation. Standing to void often helps relieve the bladder, especially after surgery. Option A, having him drink several glasses of water, may not be as effective as the client might already be adequately hydrated. Option B, Crede maneuver, is a technique for emptying the bladder by applying manual pressure and is not the first-line intervention for a client who cannot void post-surgery. Option D, waiting 2 hours before trying to void again, may delay necessary intervention if the client is experiencing urinary retention.

Correct Answer: B

Rationale: The correct first action for a client with COPD experiencing increased shortness of breath and fatigue is to check the client's oxygen saturation. This assessment helps the nurse evaluate the client's respiratory status promptly. Administering a bronchodilator (Choice A) may be necessary but should come after assessing the oxygen saturation. Repositioning the client to a high Fowler's position (Choice C) can help improve breathing but should not precede oxygen saturation assessment. Administering oxygen via nasal cannula (Choice D) may be needed based on the oxygen saturation results, but assessing it first is crucial.

Correct Answer: B

Rationale: The correct intervention to help manage the client's pain in acute pancreatitis is to place the client in a side-lying position with knees bent. This position can alleviate abdominal pain by reducing pressure on the pancreas and improving comfort. Encouraging deep breathing exercises (Choice A) is beneficial for other conditions but may not directly help alleviate abdominal pain in pancreatitis. Administering oral analgesics (Choice C) may be necessary but is not the initial priority for managing pain in acute pancreatitis. Encouraging the client to take small sips of water (Choice D) is important for hydration but is not directly related to pain management in this context.