a client with a history of chronic obstructive pulmonary disease copd is admitted with pneumonia which assessment finding is most concerning to the nu
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Nursing Elites

HESI RN

RN HESI Exit Exam

1. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which assessment finding is most concerning to the nurse?

Correct answer: C

Rationale: The correct answer is C: 'Use of accessory muscles.' In a client with a history of COPD, the use of accessory muscles indicates increased work of breathing and may signal respiratory failure, necessitating immediate intervention. This finding is concerning as it suggests the client is struggling to breathe adequately. Oxygen saturation of 90% (choice A) is low but may be expected in COPD patients; it requires monitoring and intervention but is not as immediately concerning as the use of accessory muscles. A respiratory rate of 24 breaths per minute (choice B) is within a normal range and, although slightly elevated, may be a typical response to pneumonia. Inspiratory crackles (choice D) can be a common finding in pneumonia and are not as indicative of impending respiratory failure as the use of accessory muscles.

2. When planning care for a 10-year-old child with pneumonia receiving oxygen at 5l/min per nasal cannula, what principle of oxygen administration should the nurse consider?

Correct answer: A

Rationale: The correct principle of oxygen administration to consider is to avoid administering oxygen at high levels for extended periods. High levels of oxygen for prolonged periods can lead to oxygen toxicity, especially in pediatric patients. Increasing the oxygen flow rate based on tachypnea may not be necessary and can potentially lead to oxygen toxicity. Gradually reducing oxygen levels after symptoms improve may compromise the child's oxygenation. While humidifying oxygen is important to prevent drying of mucous membranes, the primary concern in this case is to avoid high oxygen levels for an extended duration to prevent oxygen toxicity.

3. A client with liver cirrhosis is admitted with ascites and jaundice. Which assessment finding is most concerning?

Correct answer: C

Rationale: An ammonia level of 80 mcg/dL is elevated and concerning in a client with liver cirrhosis, as it may indicate hepatic encephalopathy. Elevated ammonia levels can lead to cognitive impairment, altered mental status, and even coma. Serum albumin, bilirubin, and prothrombin time are also important markers in liver cirrhosis but are not as directly associated with the risk of hepatic encephalopathy as elevated ammonia levels.

4. When administering ceftriaxone sodium (Rocephin) intravenously to a client, which assessment finding requires the most immediate intervention by the nurse?

Correct answer: A

Rationale: The correct answer is A: Stridor. Stridor is a high-pitched, noisy breathing sound that indicates a potential airway obstruction, which can be caused by an allergic reaction. This finding requires immediate intervention by the nurse to ensure the client's airway is patent and to prevent respiratory distress. Nausea, headache, and pruritus are potential side effects of ceftriaxone sodium but do not pose immediate life-threatening risks compared to airway obstruction indicated by stridor.

5. The mother of a one-month-old boy born at home brings the infant to his first well-baby visit. She mentions that he was born two weeks after his due date and is a 'good, quiet baby' who almost never cries. To assess for hypothyroidism, what question is most important for the nurse to ask the mother?

Correct answer: B

Rationale: The correct answer is B. Sleepiness and difficulty feeding are key signs of congenital hypothyroidism, which requires early diagnosis and treatment. Asking about immunizations (choice A) is important but not directly related to assessing hypothyroidism. The feeding method (choice C) is relevant for overall health but not specific to hypothyroidism. Inquiring about relatives with birth defects (choice D) is not the most crucial question to assess hypothyroidism in this scenario.

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