an adult male who fell from a roof and fractured his left femur is admitted for surgical stabilization after having a soft cast applied in the emergen
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Nursing Elites

HESI RN

HESI RN Exit Exam 2024 Quizlet

1. An adult male who fell from a roof and fractured his left femur is admitted for surgical stabilization after having a soft cast applied in the emergency department. Which assessment finding warrants immediate intervention by the nurse?

Correct answer: A

Rationale: In a patient with a fractured femur, weak palpable distal pulses can indicate compromised circulation to the lower extremity. This finding suggests a potential vascular compromise that requires immediate intervention to prevent further complications like compartment syndrome or ischemia. Pain at the fracture site, mild swelling of the leg, and bruising around the fracture site are expected following such an injury and surgical stabilization, and while they should be monitored, they do not require immediate intervention like addressing compromised circulation.

2. A client with a history of chronic kidney disease (CKD) is admitted with hyperkalemia. Which assessment finding requires immediate intervention?

Correct answer: A

Rationale: Peaked T waves on the ECG are a critical finding in hyperkalemia as they indicate potential life-threatening cardiac arrhythmias. Immediate intervention is necessary to prevent cardiac complications such as ventricular tachycardia or fibrillation. Bradycardia, decreased deep tendon reflexes, and muscle weakness are not typically associated with hyperkalemia and do not pose the same level of immediate risk to the client's life.

3. A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline?

Correct answer: D

Rationale: The correct answer is D: Toasted wheat bread and jelly. Dairy products decrease the effect of tetracycline, so the nurse should instruct the client to avoid them. Toast, which contains no dairy products, may help decrease gastrointestinal symptoms. Choices A, B, and C contain dairy products, which should be avoided when taking tetracycline.

4. A female client reports that she drank a liter of a solution to cleanse her intestines but vomited immediately. How many ml of fluid intake should the nurse document?

Correct answer: C

Rationale: The correct answer is 760 ml. After vomiting 240 ml (1 cup), the nurse should document the remaining 760 ml as the fluid intake. Choice A (240 ml) is the amount vomited, not the total intake. Choice B (500 ml) and Choice D (1000 ml) are the total intake, not considering the vomiting.

5. The nurse determines that a client's pupils constrict as they change focus from a far object. What documentation should the nurse enter about this finding?

Correct answer: A

Rationale: The correct answer is A: 'Pupils reactive to accommodation.' When pupils constrict as the client changes focus from a far object to a near one, it indicates a normal response known as accommodation. This physiological process allows the eyes to adjust their focus, and it is a healthy finding. Choice B is incorrect because nystagmus is an involuntary eye movement, not related to the change in focus. Choice C is irrelevant to the scenario and does not describe the observed finding. Choice D refers to pupillary constriction in response to light, not accommodation to changes in focus.

Similar Questions

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A client with a history of chronic kidney disease (CKD) is admitted with hyperkalemia. Which intervention should the nurse implement first?
A client with a history of chronic kidney disease (CKD) is admitted with hyperkalemia. Which clinical finding is most concerning?
In a client with cirrhosis admitted with ascites and jaundice, which clinical finding requires immediate intervention?
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