a client is admitted with a diagnosis of sepsis which assessment finding is most concerning to the nurse
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Nursing Elites

HESI RN

HESI RN Exit Exam

1. A client is admitted with a diagnosis of sepsis. Which assessment finding is most concerning to the nurse?

Correct answer: D

Rationale: A blood pressure of 90/60 mmHg in a client with sepsis is concerning for septic shock, a life-threatening condition that requires immediate intervention. Hypotension is a severe manifestation of sepsis that can lead to poor tissue perfusion and organ failure. While the other assessment findings such as an elevated temperature, increased heart rate, and respiratory rate are also common in sepsis, hypotension is particularly alarming as it indicates a critical state of shock and necessitates urgent medical attention.

2. While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

Correct answer: A

Rationale: The correct answer is A: 'Elevated blood pressure must be anticipated and identified quickly.' Acute glomerulonephritis can lead to significant hypertension, making it crucial to monitor blood pressure frequently to promptly identify any elevation. Choice B is incorrect because while monitoring can help assess medication effectiveness, the primary reason for frequent blood pressure checks in this case is to detect elevated blood pressure. Choice C is incorrect as not all hospitalized children require such frequent blood pressure monitoring. Choice D is incorrect as the primary reason for monitoring blood pressure is to detect hypertension, rather than solely focusing on potential kidney damage.

3. The nurse is caring for a client with a chest tube in place following a pneumothorax. Which finding requires immediate intervention?

Correct answer: C

Rationale: Subcutaneous emphysema requires immediate intervention in a client with a chest tube following a pneumothorax as it can indicate a pneumothorax recurrence or air leak. Oxygen saturation of 95% is within the normal range and does not require immediate intervention. Crepitus around the insertion site can be expected post-procedure and may not necessitate immediate action. Drainage of 50 ml per hour is a normal finding and does not raise immediate concerns.

4. Following a lumbar puncture, a client voices several complaints. What complaint indicates to the nurse that the client is experiencing a complication?

Correct answer: D

Rationale: The correct answer is D. A post-lumbar puncture headache, ranging from mild to severe, may occur as a result of leakage of cerebrospinal fluid at the puncture site. This complication is usually managed by bed rest, analgesics, and hydration. Choices A, B, and C do not directly indicate complications associated with a lumbar puncture. Pain in the lower back when moving legs, a sore throat when swallowing, and nausea with a feeling of vomiting are not typical complications of lumbar puncture.

5. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which intervention is most important?

Correct answer: C

Rationale: Administering insulin is the most important intervention in managing diabetic ketoacidosis. In DKA, there is a lack of insulin leading to hyperglycemia and ketosis. Insulin administration helps to reduce blood glucose levels and correct metabolic acidosis, which are crucial in treating DKA. Administering intravenous fluids helps with dehydration, monitoring urine output is important to assess renal function, but the priority is addressing the underlying cause of DKA by administering insulin. Administering 50% dextrose IV push is incorrect as it would further elevate blood glucose levels, which is contraindicated in DKA.

Similar Questions

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