the nurse assesses a clients wound what type of wound requires immediate intervention by the nurse
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Nursing Elites

HESI RN

RN HESI Exit Exam Capstone

1. The nurse assesses a client’s wound. What type of wound requires immediate intervention by the nurse?

Correct answer: A

Rationale: Lacerations, especially deep ones, are prone to bacterial contamination and may require immediate intervention to prevent infection. Abrasions, contusions, and ulcerations are not as likely to lead to immediate serious complications like infections as lacerations.

2. The home care nurse visits a client who has cancer. The client reports having a good appetite but experiencing nausea when smelling food cooking. Which action should the nurse implement?

Correct answer: A

Rationale: In some cases, the smell of food cooking can trigger nausea in cancer patients. Cooking food outside reduces the intensity of odors that could trigger nausea, helping the client maintain adequate nutrition. Providing anti-nausea medication (Choice B) may not address the root cause of the nausea triggered by the smell of cooking food. Suggesting cold water (Choice C) or smaller, frequent meals (Choice D) may not directly address the issue of cooking odors triggering nausea, which is specific to this client's situation.

3. A 17-year-old adolescent reports flu-like symptoms and is brought to the emergency room. What intervention should the nurse implement first?

Correct answer: B

Rationale: The correct answer is to place a mask on the client. This intervention is crucial in preventing the spread of infections like the flu, especially in a healthcare setting where the risk of transmission is high. Assessing the client's temperature (Choice A) can be important but is not the priority in this situation. Obtaining a chest X-ray (Choice C) and determining the client's blood pressure (Choice D) are not the immediate interventions needed for a 17-year-old reporting flu-like symptoms.

4. The mother of a 2-day-old infant girl expresses concern about a 'flea bite' type rash on her daughter's body. The nurse identifies a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer?

Correct answer: C

Rationale: The rash described is typical of erythema toxicum neonatorum, a common and benign newborn rash that resolves on its own within a few days. No treatment is necessary, and the nurse should reassure the mother. Choice A is incorrect as the rash is self-limiting and does not require monitoring for worsening signs or fever. Choice B is incorrect as erythema toxicum neonatorum is not caused by an allergic reaction to laundry detergent. Choice D is incorrect as this rash is not indicative of a bacterial infection that requires antibiotics.

5. The nurse has received funding to design a health promotion project for African American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

Correct answer: A

Rationale: The most important resource in designing a health promotion project for African American women at risk for breast cancer is the participation of community leaders in planning the program. Involving community leaders helps ensure that the program is culturally relevant, addresses the specific needs of the target population, and fosters trust and engagement. While the latest research on breast cancer risk factors, partnership with local healthcare providers, and health surveys of African American women are valuable resources, they are not as crucial as community involvement for tailoring the program effectively.

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