HESI RN
HESI Fundamentals Quizlet
1. A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal cannula at 4 liters per minute. Which assessment finding indicates a need for immediate action?
- A. The client's respiratory rate is 14 breaths per minute.
- B. The client's oxygen saturation is 92%.
- C. The client reports shortness of breath.
- D. The client's respiratory rate is 24 breaths per minute.
Correct answer: C
Rationale: A report of shortness of breath (C) indicates that the client is not tolerating the oxygen therapy well and may need an adjustment. Shortness of breath is a critical symptom in a client with COPD, as it signifies potential respiratory distress. A respiratory rate of 14 (A) is within an acceptable range for a client with COPD and does not require immediate action. An oxygen saturation of 92% (B) is slightly lower but still acceptable in COPD patients. Although a respiratory rate of 24 (D) is higher, it is not as immediately concerning as shortness of breath in this context.
2. When working with a large population of African-American clients at a community health center, which priority assessment should a nurse include?
- A. Measure height and weight.
- B. Assess blood pressure.
- C. Observe for any signs of abuse.
- D. Ask about medications.
Correct answer: B
Rationale: Assessing blood pressure is the priority assessment when working with a population of African-American clients due to the high prevalence of hypertension in this group. African Americans have a higher risk of hypertension, which can lead to complications like end-stage renal disease. Monitoring blood pressure allows for the early detection and management of hypertension. While measuring height and weight, observing for signs of abuse, and asking about medications are important assessments, assessing blood pressure is crucial in this context to address the specific health needs of African-American clients.
3. A woman is considered to be in menopause if she has experienced the cessation of her menses for a period of:
- A. 6 months
- B. 12 months
- C. 18 months
- D. 24 months
Correct answer: B
Rationale: Menopause is defined as the cessation of menses for 12 months. This period is significant because it indicates the end of a woman's reproductive years. Choices A, C, and D are incorrect as they do not align with the established criteria for defining menopause.
4. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute via nasal cannula. The client reports difficulty breathing. What action should the nurse take first?
- A. Increase the oxygen flow rate
- B. Instruct the client to breathe deeply and cough
- C. Check the client's oxygen saturation level
- D. Place the client in a high-Fowler's position
Correct answer: C
Rationale: The correct action for the nurse to take first when a client with COPD reports difficulty breathing while receiving oxygen is to check the client's oxygen saturation level. This helps in determining the adequacy of oxygenation and identifying the cause of the breathing difficulty. Increasing the oxygen flow rate (Choice A) may not be appropriate without knowing the current oxygen saturation level. Instructing the client to breathe deeply and cough (Choice B) may not address the immediate need for oxygen assessment. Placing the client in a high-Fowler's position (Choice D) can help with breathing but should come after ensuring proper oxygenation.
5. A client is diagnosed with Meniere's disease. Which problem should the nurse identify as most important in the plan of care?
- A. Social isolation related to hearing loss
- B. Risk for injury related to vertigo
- C. Impaired verbal communication
- D. Impaired hearing related to ear disease
Correct answer: B
Rationale: Vertigo is the primary symptom of Meniere's disease and can lead to falls and other injuries. Ensuring safety and addressing the risk of injury is the nurse's top priority. While social isolation and impaired hearing are significant concerns associated with Meniere's disease, the immediate danger of falls due to vertigo takes precedence in the plan of care. Impaired verbal communication, although important, is not as urgent as preventing injuries caused by vertigo.