HESI RN
HESI 799 RN Exit Exam Quizlet Questions
Question 1 of 4
The nurse is assessing the thorax and lungs of a client who is experiencing respiratory difficulty. Which finding is most indicative of respiratory distress?
Correct Answer: A
Rationale: The correct answer is A: Contractions of the sternocleidomastoid muscle. Contractions of the sternocleidomastoid muscle suggest that the client is using accessory muscles to breathe, which is a clear sign of respiratory distress. This finding indicates that the client is working harder to breathe, typically seen in conditions like asthma, COPD, or respiratory failure. Choices B, C, and D are not the most indicative of respiratory distress. A respiratory rate of 20 breaths/min falls within the normal range. Downward movement of the diaphragm with inspiration is a normal finding indicating effective diaphragmatic breathing. A pulse oximetry reading of SpO2 95% is within the normal range and does not necessarily indicate respiratory distress.
Question 2 of 4
In caring for a client receiving the aminoglycoside antibiotic gentamicin, what diagnostic test should the nurse prioritize monitoring?
Correct Answer: B
Rationale: The correct answer is B: Serum creatinine. Aminoglycosides, such as gentamicin, are known to cause nephrotoxicity, which can lead to kidney damage. Monitoring serum creatinine levels is crucial in assessing renal function and detecting any potential kidney problems early. Choices A, C, and D are incorrect because urinalysis primarily assesses urine composition, serum osmolarity measures the concentration of solutes in the blood, and liver enzymes are not directly impacted by aminoglycoside antibiotics like gentamicin.
Question 3 of 4
While performing a skin inspection for a female adult client, the nurse observes a rash that is well circumscribed, has silvery scales and plaques, and is located on the elbows and knees. These assessment findings are likely to indicate which condition?
Correct Answer: C
Rationale: The correct answer is C, Psoriasis. Psoriasis commonly presents with well-circumscribed, silvery scales and plaques, typically found on extensor surfaces like elbows and knees. Tinea corporis (A) presents as a circular rash, herpes zoster (B) presents as a painful rash following a dermatomal pattern, and drug reactions (D) have variable presentations not specific to elbows and knees with silvery scales and plaques.
Question 4 of 4
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?
Correct Answer: A
Rationale: In this scenario, the child who requires the most immediate intervention by the nurse is the 11-year-old with a headache, nausea, and projectile vomiting (Option A). This presentation raises concern for a potential head injury, possibly indicating a more serious condition like a concussion or intracranial bleeding, which requires urgent medical attention to prevent further complications. The other options are not as urgent: - Option B: A 5-year-old with a broken arm can be painful and distressing but does not pose an immediate life-threatening risk. - Option C: A 7-year-old with minor abrasions may require wound care but is not a priority compared to a potential head injury. - Option D: A 9-year-old with a twisted ankle can be managed with rest, ice, compression, and elevation (RICE) and does not require immediate intervention. Understanding the urgency of different clinical presentations is crucial in triaging patients effectively in emergency situations. Recognizing signs of potentially serious conditions and prioritizing care based on the level of urgency can significantly impact patient outcomes. This question highlights the importance of quick decision-making and prioritization skills in emergency care settings.