HESI RN
HESI 799 RN Exit Exam Quizlet
1. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which finding requires immediate intervention?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 24 breaths per minute
- C. Use of accessory muscles
- D. Blood pressure of 110/70 mmHg
Correct answer: C
Rationale: The correct answer is C. The use of accessory muscles indicates increased work of breathing and may signal respiratory failure in a client with COPD, requiring immediate intervention. Oxygen saturation of 90% is within an acceptable range for COPD patients on supplemental oxygen. A respiratory rate of 24 breaths per minute is slightly elevated but not an immediate concern. A blood pressure of 110/70 mmHg is within the normal range and does not require immediate intervention in this scenario.
2. While auscultating heart sounds, the nurse hears a swishing sound. How should this sound be documented?
- A. Heart murmur.
- B. Murmur.
- C. S3 sound.
- D. S4 sound.
Correct answer: B
Rationale: The correct answer is B: 'Murmur.' A murmur is a swishing sound heard during auscultation, typically caused by turbulent blood flow through the heart or valves. Choices C and D, 'S3 sound' and 'S4 sound,' refer to specific heart sounds associated with different cardiac conditions, not the general description of a swishing sound. Choice A, 'Heart murmur,' is redundant as 'murmur' alone is sufficient to describe the swishing sound heard.
3. A patient presents with severe chest pain radiating to the left arm. Which of the following diagnostic tests is the priority?
- A. Complete blood count (CBC)
- B. Electrocardiogram (ECG)
- C. Chest X-ray
- D. Serum electrolytes
Correct answer: B
Rationale: In a patient presenting with severe chest pain radiating to the left arm, the priority diagnostic test is an Electrocardiogram (ECG) to assess for myocardial infarction. An ECG can quickly identify changes indicative of ischemia or infarction, guiding prompt management. A Complete Blood Count (CBC) may provide some information but is not the primary test for evaluating chest pain related to myocardial infarction. A Chest X-ray can be useful in assessing lung pathologies or certain cardiac conditions; however, it does not provide immediate information on myocardial infarction, making it a secondary option in this scenario. Serum electrolytes may become important in later stages but do not offer immediate insights into myocardial infarction. Therefore, they are a lower priority compared to obtaining an ECG for timely diagnosis and intervention.
4. Upon admission, a female client with breast cancer, liver, and spine metastases presents with constant, severe pain despite the continuous use of oxycodone (Percodan) and amitriptyline (Elavil) at home for pain management. What information is most crucial for the nurse to gather during the admission assessment?
- A. Sensory pattern, area, intensity, and nature of the pain.
- B. Identification of trigger points through palpation and manual pressure on painful areas.
- C. Current schedule and total dosages of medications used for breakthrough pain.
- D. Assessment of sympathetic responses indicative of acute pain onset.
Correct answer: A
Rationale: The most critical information for the nurse to obtain during the admission assessment of a client with severe pain due to breast cancer metastasis to the liver and spine is the sensory pattern, area, intensity, and nature of the pain. Understanding these details is essential to tailor appropriate pain management therapy effectively. By assessing the sensory pattern, area, intensity, and nature of pain, the nurse can better determine the underlying cause and choose the most suitable interventions to address the client's pain and improve their quality of life. Trigger points, medication dosages, and sympathetic responses are also important aspects of pain assessment but understanding the sensory aspects of pain is fundamental for providing optimal care in this scenario.
5. Oligomenorrhea is defined as a cycle longer than:
- A. 28 days
- B. 30 days
- C. 35 days
- D. 40 days
Correct answer: C
Rationale: Oligomenorrhea is defined as a menstrual cycle longer than 35 days. A cycle of 28 days (Choice A) is within the normal range, and not considered oligomenorrhea. Similarly, 30 days (Choice B) and 40 days (Choice D) are also within the normal range. The correct definition of oligomenorrhea specifically refers to cycles longer than 35 days, making Choice C the correct answer.