HESI RN
HESI RN Exit Exam 2024 Quizlet Capstone
1. A client with a history of asthma reports using an albuterol inhaler more frequently than prescribed. Which action should the nurse take first?
- A. Notify the healthcare provider immediately
- B. Schedule a pulmonary function test
- C. Assess the client's respiratory status
- D. Instruct the client to decrease inhaler use
Correct answer: C
Rationale: Increased use of a rescue inhaler like albuterol may indicate worsening asthma symptoms. The nurse should first assess the client's respiratory status to determine the severity of the issue and the next steps in care. Option A is not the first action because assessing the client's condition should precede notifying the healthcare provider. Option B, scheduling a pulmonary function test, is not the priority as immediate assessment of the client's respiratory status is crucial. Instructing the client to decrease inhaler use should come after assessing the client's condition to ensure the appropriate intervention.
2. A client with diabetes mellitus is admitted with an infected foot ulcer. What intervention is most important for the nurse to implement?
- A. Obtain a wound culture for testing.
- B. Administer prescribed IV antibiotics.
- C. Elevate the affected foot to reduce swelling.
- D. Consult the wound care nurse for assessment.
Correct answer: B
Rationale: Administering prescribed IV antibiotics is the most crucial intervention in managing an infected foot ulcer in a client with diabetes mellitus. Antibiotics help combat the infection and prevent its spread systemically, which is vital in diabetic clients to prevent serious complications like sepsis. While obtaining a wound culture (Choice A) may provide valuable information for targeted antibiotic therapy, administering antibiotics promptly takes precedence to prevent the infection from worsening. Elevating the affected foot (Choice C) can help reduce swelling but is not as urgent as administering antibiotics. Consulting the wound care nurse (Choice D) may be beneficial for long-term wound management but does not address the immediate need to control the infection.
3. A client is experiencing acute bronchospasm. What is the nurse's priority intervention?
- A. Administer a nebulizer treatment of albuterol.
- B. Start an IV infusion of normal saline.
- C. Administer oxygen at 4L/min via nasal cannula.
- D. Position the client in a high Fowler's position.
Correct answer: A
Rationale: The correct answer is to administer a nebulizer treatment of albuterol. In acute bronchospasm, the priority intervention is to deliver a bronchodilator like albuterol to open the airways and improve breathing. Starting an IV infusion of normal saline (Choice B) may be necessary but not the priority in this situation. Administering oxygen at 4L/min via nasal cannula (Choice C) is important but not the first intervention for bronchospasm. Positioning the client in a high Fowler's position (Choice D) can help with breathing but is not the priority over administering a bronchodilator.
4. The nurse is providing discharge instructions to a client after a total hip replacement. Which statement by the client indicates a need for further teaching?
- A. I will avoid crossing my legs when sitting.
- B. I will use a raised toilet seat to prevent bending too far.
- C. I should keep my legs together to prevent dislocation.
- D. I will use a walker when moving around initially.
Correct answer: C
Rationale: The correct answer is C. Clients who have had a hip replacement should not keep their legs together to prevent dislocation. This position increases the risk of hip dislocation. Choices A, B, and D are correct statements. Avoiding crossing legs, using a raised toilet seat to prevent excessive bending, and using a walker when moving around initially are all appropriate measures to ensure proper recovery and prevent complications after a total hip replacement.
5. A client with chronic obstructive pulmonary disease (COPD) is prescribed home oxygen therapy. What teaching should the nurse provide?
- A. Ensure that the client uses oxygen continuously at night.
- B. Instruct the client to avoid smoking and exposure to smoke.
- C. Teach the client how to clean and replace the oxygen tubing.
- D. Instruct the client to increase their fluid intake.
Correct answer: C
Rationale: The correct teaching for a client with COPD prescribed home oxygen therapy is to educate them on how to clean and replace the oxygen tubing. This is crucial to prevent infections and ensure the effectiveness of the oxygen delivery system. Option A is not necessary as oxygen therapy is usually prescribed as needed, not continuously at night. While smoking cessation and avoiding smoke exposure are important in COPD management, it is not directly related to home oxygen therapy. Increasing fluid intake is beneficial for some conditions but is not specifically related to home oxygen therapy for COPD.
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