before preparing a client for the first surgical case of the day a part time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub
Logo

Nursing Elites

HESI RN

HESI RN Exit Exam

1. Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3-minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide?

Correct answer: D

Rationale: The correct answer is to direct the nurse to continue the surgical hand scrub for a 5-minute duration. Surgical hand scrubs should last for 5 to 10 minutes, ensuring thorough cleaning and disinfection. Choice A is incorrect because the nurse should be guided to complete the scrub properly rather than having someone else do it. Choice B is incorrect as it does not address the duration of the hand scrub. Choice C is incorrect as it suggests a 3-minute hand scrub is sufficient, which is inadequate for proper preparation before surgery.

2. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which assessment finding requires immediate intervention?

Correct answer: C

Rationale: The correct answer is C. The use of accessory muscles is most concerning in a client with COPD receiving supplemental oxygen as it indicates increased work of breathing, requiring immediate intervention. Oxygen saturation of 90% is acceptable in a client with COPD. A respiratory rate of 24 breaths per minute is slightly elevated but not as critical as the use of accessory muscles. Inspiratory crackles may be present in clients with COPD due to underlying lung changes but do not require immediate intervention unless associated with other concerning symptoms.

3. The nurse is assessing a client with right-sided heart failure. Which finding requires immediate intervention?

Correct answer: C

Rationale: In a client with right-sided heart failure, crackles in the lungs are the most concerning finding as they indicate pulmonary congestion, which requires immediate intervention. Crackles suggest fluid accumulation in the lungs, leading to impaired gas exchange and potential respiratory distress. Jugular venous distention (Choice A) and peripheral edema (Choice B) are common findings in right-sided heart failure but do not indicate acute deterioration requiring immediate intervention. Elevated liver enzymes (Choice D) may be seen in chronic heart failure but do not warrant immediate action compared to the urgent need to address pulmonary congestion indicated by crackles in the lungs.

4. A client with a history of myocardial infarction is admitted with chest pain. Which laboratory value should the nurse monitor closely?

Correct answer: C

Rationale: The correct answer is C: Troponin level. Troponin levels should be closely monitored in a client with chest pain and a history of myocardial infarction to assess for ongoing myocardial injury. Troponin is a specific marker for myocardial damage. Monitoring white blood cell count (choice A) is not directly related to myocardial infarction. Serum creatinine (choice B) is more indicative of renal function rather than cardiac status. Hemoglobin level (choice D) is important but does not directly reflect ongoing myocardial injury.

5. In a client with cirrhosis admitted with jaundice and ascites, which laboratory value is most concerning?

Correct answer: C

Rationale: A serum ammonia level of 80 mcg/dl is most concerning in a client with cirrhosis as it may indicate hepatic encephalopathy, requiring immediate intervention. Elevated ammonia levels are associated with impaired liver function and can lead to mental status changes. Serum bilirubin (Choice A) is elevated in cirrhosis but not as concerning for acute intervention as high ammonia levels. Serum albumin (Choice B) and serum sodium (Choice D) levels are important in cirrhotic patients but are not as directly associated with hepatic encephalopathy as ammonia levels.

Similar Questions

A client with a history of alcoholism is admitted with confusion, ataxia, and nystagmus. Which nursing intervention is a priority for this client?
When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to do?
An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement?
Which class of drugs is the only source of a cure for septic shock?
A client is admitted with a possible myocardial infarction. Which laboratory test result is most indicative of a myocardial infarction?

Access More Features

HESI RN Basic
$89/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses