HESI 799 RN Exit Exam Quizlet

Question 1 of 5

A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication?

A. Increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure B. The antagonistic interaction among the various blood pressure medications has reduced their effectiveness C. The additive effect of multiple medications has caused the blood pressure to drop too low. D. The synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension.

Correct Answer: C

Rationale: When medications with a similar action are administered, an additive effect occurs that is the sum of the effects of each medication. In this case, several medications that all lower blood pressure, when administered together, resulted in hypotension.

Question 2 of 5

A client is admitted with a diagnosis of pneumonia and is receiving IV antibiotics. Which assessment finding indicates that the treatment is effective?

A. Client reports less chest pain. B. Client's white blood cell count is decreasing. C. Client has a decreased respiratory rate. D. Client has clear breath sounds.

Correct Answer: D

Rationale: The correct answer is D. Clear breath sounds indicate that the pneumonia is resolving and the treatment is effective. Breath sounds are often muffled or crackling in pneumonia due to the presence of fluid or inflammation in the lungs. Clear breath sounds suggest that the air is moving freely through the lungs, indicating improvement.

Choices A, B, and C are less specific indicators of pneumonia resolution. While less chest pain and a decreasing white blood cell count can be positive signs, they are not as direct in indicating the effectiveness of pneumonia treatment as the presence of clear breath sounds. A decreased respiratory rate could be seen in various conditions and may not solely indicate the resolution of pneumonia.

Question 3 of 5

The nurse reviews the laboratory findings of a client with an open fracture of the tibia. The white blood cell (WBC) count and erythrocyte sedimentation rate (ESR) are elevated. Before reporting this information to the healthcare provider, what assessment should the nurse obtain?

A. Appearance of wound B. Pain level C. Presence of fever D. Mobility status

Correct Answer: A

Rationale: The correct answer is A: Appearance of wound. Elevated WBC and ESR levels suggest a possible infection in the client with an open fracture. Assessing the wound's appearance is crucial to evaluate for signs of infection, such as redness, warmth, swelling, or drainage. By assessing the wound first, the nurse can provide important information to the healthcare provider regarding the potential infection, which may require immediate intervention.

Choices B, C, and D are important assessments in caring for a client with an open fracture; however, in this scenario, the priority is to assess the wound for signs of infection due to the elevated WBC and ESR levels.

Question 4 of 5

The nurse is triaging several children as they present to the emergency room after an accident. Which child requires the most immediate intervention by the nurse?

A. An 11-year-old with a headache, nausea, and projectile vomiting B. A 5-year-old with a broken arm C. A 7-year-old with minor abrasions D. A 9-year-old with a twisted ankle

Correct Answer: A

Rationale: The correct answer is A. Projectile vomiting in a child with a headache could indicate increased intracranial pressure, requiring immediate attention.

Choices B, C, and D do not present with symptoms indicating potentially life-threatening conditions that require urgent intervention.

Question 5 of 5

During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?

A. Respiratory apnea of 30 seconds B. Oxygen saturation rate of 88% C. Eight premature ventricular beats every minute D. Disconnected monitor signal for the last 6 minutes.

Correct Answer: A

Rationale: The correct answer is A: Respiratory apnea of 30 seconds. Respiratory apnea indicates a cessation of breathing, which is a life-threatening emergency requiring immediate intervention. Priority should be given to assessing and managing airway, breathing, and circulation. Option B, oxygen saturation rate of 88%, can indicate hypoxemia, but addressing the lack of breathing takes precedence. Option C, eight premature ventricular beats every minute, and option D, a disconnected monitor signal, are important but do not pose an immediate threat to the client's life compared to respiratory apnea.

Nurselytic

HESI RN

HESI RN