HESI RN
HESI 799 RN Exit Exam Capstone
1. A client is admitted with a suspected gastrointestinal bleed. What assessment finding requires immediate intervention?
- A. Bright red blood in the vomit.
- B. Elevated blood pressure and heart rate.
- C. Coffee ground emesis.
- D. Dark, tarry stools.
Correct answer: D
Rationale: Dark, tarry stools indicate the presence of digested blood in the gastrointestinal tract, signifying a higher gastrointestinal bleed. This finding requires immediate intervention due to the potential severity of the bleed. Bright red blood in the vomit may indicate active bleeding but is not as concerning as digested blood. Elevated blood pressure and heart rate are common responses to bleeding but do not provide direct evidence of the source or severity of the bleed. Coffee ground emesis is indicative of partially digested blood and is a concern but not as urgent as dark, tarry stools.
2. An unresponsive male victim of a diving accident is brought to the emergency department where immediate surgery is required to save his life. No family members are available. What action should the nurse take first?
- A. Ask the friend to sign an informed consent.
- B. Notify the unit manager that a court order is needed.
- C. Continue providing life support until a guardian is found.
- D. Proceed with surgery preparation without consent.
Correct answer: D
Rationale: In emergency situations where immediate surgery is required to save a patient's life and no family members are available, consent can be waived to proceed with necessary interventions. The priority in this scenario is to proceed with surgery preparation without waiting for consent, as any delay could jeopardize the patient's life. Asking the friend to sign informed consent or notifying the unit manager for a court order would cause unnecessary delays, which are not advisable in this critical situation. Continuing life support until a guardian is found is not the most appropriate action when immediate surgical intervention is necessary.
3. A client presents to the emergency department with a severe exacerbation of asthma. The nurse notes that the client is using accessory muscles to breathe and has an oxygen saturation of 86%. Which intervention should the nurse implement first?
- A. Place the client in a high-Fowler's position
- B. Obtain a peak flow reading
- C. Administer a bronchodilator
- D. Administer oxygen therapy
Correct answer: D
Rationale: The first priority in an acute asthma exacerbation is to administer oxygen to improve the client's oxygen saturation. In this scenario, the client has a low oxygen saturation level of 86%, indicating hypoxemia, which can be life-threatening. Administering oxygen therapy will help improve oxygenation and support vital organ function. Once the oxygen levels are stabilized, further interventions such as bronchodilators can be implemented. Placing the client in a high-Fowler's position may also be beneficial, but ensuring adequate oxygenation takes precedence in this critical situation. Obtaining a peak flow reading is important for asthma management but is not the first intervention needed in a client with severe hypoxemia.
4. What pathophysiological events occur sequentially in the development of atherosclerosis?
- A. Foam cells release growth factors.
- B. Smooth muscle grows over fatty streaks creating fibrous plaques.
- C. Macrophages consume low-density lipoprotein (LDL) and create foam cells.
- D. Arterial endothelium injury causes inflammation.
Correct answer: D
Rationale: The correct sequence of pathophysiological events in the development of atherosclerosis starts with arterial endothelium injury causing inflammation. This inflammation triggers the formation of foam cells by macrophages consuming low-density lipoprotein (LDL). Subsequently, smooth muscle grows over fatty streaks, creating fibrous plaques. Therefore, option D is the correct answer. Choices A, B, and C are incorrect because they do not reflect the accurate chronological order of events in the pathogenesis of atherosclerosis.
5. A client is admitted for first and second-degree burns on the face, neck, anterior chest, and hands. The nurse's priority should be
- A. Cover the areas with dry sterile dressings
- B. Assess for dyspnea or stridor
- C. Initiate intravenous therapy
- D. Administer pain medication
Correct answer: B
Rationale: Assessing for dyspnea or stridor is crucial as these are signs of airway compromise, which is a priority concern in burns involving the face. Burns on the face can lead to airway swelling or compromise due to airway proximity, making respiratory assessment the top priority. Covering the areas with dry sterile dressings, initiating intravenous therapy, and administering pain medication are important interventions but assessing for airway issues takes precedence in this situation.
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