HESI RN
HESI RN Exit Exam 2024 Quizlet
1. A client with chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which intervention should the nurse implement first?
- A. Administer oxygen therapy as prescribed.
- B. Elevate the head of the bed.
- C. Obtain a sputum culture.
- D. Administer antibiotics as prescribed.
Correct answer: A
Rationale: The correct answer is to administer oxygen therapy as prescribed. In COPD exacerbation, the priority is to improve oxygenation. Administering oxygen therapy helps ensure an adequate oxygen supply to the body's tissues. Elevating the head of the bed can improve ventilation but is not the first intervention needed in this situation. Obtaining a sputum culture and administering antibiotics are important in COPD exacerbation but come after ensuring proper oxygenation.
2. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which assessment finding is most concerning to the nurse?
- A. Barrel-shaped chest
- B. Use of accessory muscles
- C. Oxygen saturation of 85%
- D. Respiratory rate of 28 breaths per minute
Correct answer: C
Rationale: An oxygen saturation of 85% is significantly low for a client with COPD and indicates hypoxemia, requiring immediate intervention. In COPD, the body's ability to oxygenate adequately is already compromised, so a saturation of 85% is particularly concerning. A barrel-shaped chest and use of accessory muscles are common findings in COPD due to chronic air trapping and increased work of breathing. While a respiratory rate of 28 breaths per minute is elevated, a low oxygen saturation is a more critical finding that necessitates prompt attention.
3. An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The nurse notices the client has more energy and is giving her belongings away. Which intervention is best for the nurse to implement?
- A. Support the client by praising her progress.
- B. Ask the client if she has had any recent thoughts of harming herself.
- C. Reassure the client about the effectiveness of antidepressant drugs.
- D. Advise the client to keep her belongings for discharge.
Correct answer: B
Rationale: The correct intervention is to ask the client if she has had any recent thoughts of harming herself because increased energy and giving away belongings can be signs of suicidal ideation. Choice A is incorrect as it does not address the potential risk of self-harm. Choice C is incorrect because reassurance about medication effectiveness may not be appropriate in this situation. Choice D is incorrect as it dismisses the client's current behavior without addressing the underlying concern of potential self-harm.
4. A client with a spinal cord injury at the T1 level is admitted with a suspected deep vein thrombosis (DVT) in the right leg. Which intervention should the nurse implement first?
- A. Administer prescribed anticoagulant therapy
- B. Place the client on bedrest
- C. Elevate the client's right leg
- D. Apply compression stockings to the right leg
Correct answer: B
Rationale: The correct answer is to place the client on bedrest. Placing the client on bedrest is the priority intervention as it helps prevent the risk of embolization from the DVT, which could lead to a life-threatening pulmonary embolism. Administering anticoagulant therapy, elevating the client's right leg, or applying compression stockings are important interventions in managing DVT but should come after ensuring the client is on bedrest to prevent the dislodgment of the clot.
5. A confused, older client with Alzheimer's disease becomes incontinent of urine when attempting to find the bathroom. Which action should the nurse implement?
- A. Assist the client to a bedside commode every two hours
- B. Insert an indwelling catheter
- C. Use adult diapers to manage incontinence
- D. Restrict fluids in the evening
Correct answer: A
Rationale: The correct action for the nurse to implement is to assist the client to a bedside commode every two hours. This approach, known as scheduled toileting, is essential in managing incontinence in clients with cognitive impairments like Alzheimer's disease. By providing regular assistance to the client to use the commode, the nurse can help maintain continence and reduce accidents. Inserting an indwelling catheter (Choice B) should be avoided if possible to prevent the risk of urinary tract infections. Using adult diapers (Choice C) should be considered a last resort and not the initial intervention. Restricting fluids in the evening (Choice D) is not appropriate as it may lead to dehydration and other complications.
Similar Questions
Access More Features
HESI RN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $69.99
HESI RN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $149.99