when assessing an iv site used for fluid replacement and medication administration the client complains of tenderness when the arm is touched above th
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Nursing Elites

HESI RN

HESI RN Exit Exam 2023 Capstone

1. When assessing an IV site used for fluid replacement and medication administration, the client complains of tenderness when the arm is touched above the site. Which additional assessment finding warrants immediate intervention by the nurse?

Correct answer: D

Rationale: The correct answer is D: "Red streaks tracking the vein." Red streaks indicate phlebitis, an inflammation of the vein that can lead to serious complications like infection or thrombophlebitis. Immediate intervention is required to prevent further damage. Choice A, cool skin at the IV insertion site, could indicate decreased circulation but is not as urgent as addressing phlebitis. Choice B, presence of fluid leaking around the IV catheter, may indicate infiltration or dislodgement of the catheter, requiring intervention but not as urgently as phlebitis. Choice C, swelling above the IV site, may suggest localized inflammation but doesn't pose an immediate threat like phlebitis does.

2. The nurse is caring for a 69-year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)?

Correct answer: D

Rationale: The correct answer is D because measuring urine output is a task that falls within the UAP's scope of practice and does not require clinical decision-making. Choice A is incorrect because testing blood sugar using Accu-Chek involves interpreting results and possible adjustments, which require a licensed healthcare provider. Choice B is incorrect as discussing signs of hyperglycemia involves education and interpretation that should be done by a nurse. Choice C is incorrect since administering insulin is a high-risk task that necessitates precise dosing and monitoring, thus should not be delegated to UAP.

3. A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern?

Correct answer: B

Rationale: Fixed, dilated pupils are a sign of increased intracranial pressure or brain injury, indicating a potentially serious neurological condition. Flaccid paralysis, although concerning, may not always indicate immediate life-threatening issues. Diminished spinal reflexes and reduced sensory responses are important neurological assessments but are not as acutely concerning as fixed, dilated pupils in this context.

4. A client presents to the emergency department with a severe exacerbation of asthma. The nurse notes that the client is using accessory muscles to breathe and has an oxygen saturation of 86%. Which intervention should the nurse implement first?

Correct answer: D

Rationale: The first priority in an acute asthma exacerbation is to administer oxygen to improve the client's oxygen saturation. In this scenario, the client has a low oxygen saturation level of 86%, indicating hypoxemia, which can be life-threatening. Administering oxygen therapy will help improve oxygenation and support vital organ function. Once the oxygen levels are stabilized, further interventions such as bronchodilators can be implemented. Placing the client in a high-Fowler's position may also be beneficial, but ensuring adequate oxygenation takes precedence in this critical situation. Obtaining a peak flow reading is important for asthma management but is not the first intervention needed in a client with severe hypoxemia.

5. What are the primary pathophysiological mechanisms responsible for ascites in liver failure?

Correct answer: B

Rationale: The correct answer is B: Increased hydrostatic pressure in portal circulation. Ascites in liver failure is primarily caused by fluid shifts from the intravascular space to the interstitial space due to increased hydrostatic pressure in the portal circulation. Choice A is incorrect as ascites is not caused by decreased liver enzymes. Choice C is incorrect as high bilirubin levels are not the primary mechanism for ascites in liver failure. Choice D is incorrect as fluid shifts in ascites are due to decreased serum proteins, not increased serum proteins.

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