HESI RN
HESI 799 RN Exit Exam Quizlet
1. The parents of a 6-year-old recently diagnosed with asthma should be taught that symptoms of an acute episode of asthma are due to which physiological response?
- A. Inflammation of the mucous membrane and bronchospasm
- B. Increased mucus production and airway obstruction
- C. Hyperinflation of the lungs and alveolar collapse
- D. Bronchoconstriction and airway inflammation
Correct answer: D
Rationale: The correct answer is D: Bronchoconstriction and airway inflammation. During an acute asthma episode, bronchoconstriction and airway inflammation occur, leading to difficulty breathing. Choices A, B, and C are incorrect. Inflammation of the mucous membrane and bronchospasm (Choice A) are part of the pathophysiology of asthma but do not fully explain the symptoms during an acute episode. Increased mucus production and airway obstruction (Choice B) are also seen in asthma but are not the primary cause of acute symptoms. Hyperinflation of the lungs and alveolar collapse (Choice C) are not typical features of an acute asthma episode.
2. A client asks the nurse to call the police and states: 'I need to report that I am being abused by a nurse.' The nurse should first
- A. Focus on reality orientation to place and person
- B. Assist with the report of the client's complaint to the police
- C. Obtain more details of the client's claim of abuse
- D. Document the statement in the client's chart with a report to the manager
Correct answer: C
Rationale: The correct initial action for the nurse is to obtain more details about the client's claim of abuse. This will help the nurse better understand the situation before proceeding with any further actions. Option A is incorrect as reality orientation is not the priority in this situation. Option B is premature as more details are needed first. Option D is not the immediate step as gathering information should come before documentation and reporting.
3. The nurse receives an order to give a client iron by deep injection. The nurse knows that the reason for this route is to
- A. enhance absorption of the medication
- B. ensure that the entire dose of medication is given
- C. provide more even distribution of the drug
- D. prevent the drug from tissue irritation
Correct answer: D
Rationale: The correct answer is D. Deep injection helps to prevent tissue irritation caused by iron, which can be damaging to tissues. Option A is incorrect because deep injection does not primarily aim to enhance absorption, but rather to prevent tissue irritation. Option B is incorrect as the route of administration does not determine whether the entire dose is given. Option C is incorrect because the even distribution of the drug is not the main purpose of deep injection in this context.
4. The nurse is caring for a client with liver cirrhosis. Which assessment finding requires immediate intervention?
- A. Jaundice.
- B. Ascites.
- C. Peripheral edema.
- D. Spider angiomas.
Correct answer: D
Rationale: Spider angiomas are abnormal clusters of blood vessels near the skin surface and can be indicative of an underlying liver condition. In the context of liver cirrhosis, spider angiomas can suggest portal hypertension and liver dysfunction, which requires immediate intervention. Jaundice (choice A) is a common manifestation of liver cirrhosis but not typically an immediate intervention priority unless severe. Ascites (choice B) and peripheral edema (choice C) are also common in liver cirrhosis but do not require immediate intervention unless they are causing respiratory compromise or other urgent issues.
5. A client with Addison's disease becomes confused and weak. What is the nurse's first action?
- A. Administer a dose of hydrocortisone immediately.
- B. Check the client’s electrolyte levels.
- C. Administer a dose of normal saline.
- D. Measure the client’s blood pressure in both arms.
Correct answer: A
Rationale: The correct answer is to administer a dose of hydrocortisone immediately. In Addison's disease, confusion and weakness can be signs of an adrenal crisis. Administering hydrocortisone promptly is crucial to prevent further deterioration. Checking electrolyte levels (Choice B) is important but not the first action in managing an acute adrenal crisis. Administering normal saline (Choice C) is not the priority in this situation. Measuring blood pressure in both arms (Choice D) is not the initial action needed to address the client's confusion and weakness in Addison's disease.