an adult client is admitted to the emergency department after falling from the ladder while waiting to have a ct scan the client requests something fo
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Nursing Elites

HESI RN

HESI Exit Exam RN Capstone

1. An adult client is admitted to the emergency department after falling from a ladder. While waiting to have a CT scan, the client requests something for a severe headache. When the nurse offers a prescribed dose of acetaminophen, the client asks for something stronger. Which intervention should the nurse implement?

Correct answer: B

Rationale: In this scenario, the nurse should explain the reason for using only non-narcotics. Following head trauma, non-narcotic medications such as acetaminophen are preferred to avoid masking symptoms of neurological changes, such as increased intracranial pressure, that could worsen after stronger pain medication. Administering an anti-inflammatory medication (Choice A) may not be appropriate as it may not address the severity of the headache. Consulting the healthcare provider about a stronger medication (Choice C) is important, but the immediate need is to educate the client on the rationale for using non-narcotic medications first. Administering a stronger medication as requested (Choice D) could potentially mask important symptoms and should be avoided in this situation.

2. While changing a client's chest tube dressing, the nurse notes a cracking sensation when gentle pressure is applied to the skin at the insertion site. What should the nurse do next?

Correct answer: D

Rationale: Measuring the area of crackling and swelling is essential in monitoring the progression of subcutaneous emphysema, which can result from air leaking into the tissues around the chest tube insertion site. This technique helps evaluate the extent of the issue and guides further interventions. Applying a pressure dressing (choice A) might exacerbate the condition by trapping more air. Administering an oral antihistamine (choice B) is not indicated for subcutaneous emphysema. Assessing for allergies to topical cleaning agents (choice C) is not the priority in this situation compared to evaluating and managing the subcutaneous emphysema.

3. The nurse is assessing a client 2 hours postoperatively following an appendectomy. The nurse should intervene for which abnormal finding?

Correct answer: C

Rationale: The correct answer is C. Oxygen saturation levels below 95% indicate hypoxia and require immediate intervention. A heart rate of 88 beats per minute, a blood pressure of 100/60, and a respiratory rate of 16 are within normal ranges and do not require immediate intervention. Oxygen saturation is a critical parameter reflecting the client's oxygenation status.

4. A client who had a vasectomy is in the post-recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?

Correct answer: A

Rationale: The most important point to reinforce after a vasectomy is to continue using contraception until the healthcare provider confirms the absence of sperm in the ejaculate. Choice A is correct because it emphasizes the necessity of another form of contraception until sperm absence is confirmed. Choice B is incorrect because it focuses on how a vasectomy works anatomically rather than the need for ongoing contraception. Choice C is incorrect as it discusses post-vasectomy care but does not address the need for continued contraception. Choice D is also incorrect as it refers to general post-procedure recommendations but does not highlight the crucial aspect of using contraception until sperm absence is confirmed.

5. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is?

Correct answer: D

Rationale: In clients with altered renal function being treated at home, weekly weight is the most accurate indicator of fluid balance. Fluid retention or loss can significantly affect weight, making it a reliable measure. Choices A, B, and C are not as accurate indicators of fluid balance as weekly weight. Intake and output differences can vary in accuracy and may not capture all aspects of fluid balance. Changes in mucous membranes and skin turgor can be influenced by factors other than fluid balance, making them less precise indicators.

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