Review HESI RN Exit Exam IV (2024)

Neutrophils are a type of white blood cell involved in the body's immune response, particularly against bacterial infections. An elevated neutrophil count (neutrophilia) can indicate an acute infection or inflammation, including in wounds.

High blood glucose levels can predispose the client to infections, including wound infections. While it's important to monitor blood glucose levels, it is less directly relevant to the immediate concern of purulent drainage from the burn wound.

Hematocrit measures the proportion of red blood cells in the blood and is used to assess hydration status and oxygen-carrying capacity. In burn patients, changes in hematocrit can indicate fluid shifts and potential dehydration. Fluid shifts and dehydration can influence wound healing and overall patient condition but are not directly related to the presence of purulent drainage.

This statement demonstrates good understanding. Alcohol can affect blood sugar levels and should be consumed in moderation by people with diabetes. Limiting intake to 1-2 drinks per day (following healthcare provider's advice) is generally recommended to minimize the impact on blood sugar levels and overall health.

Exercise is crucial for managing blood glucose levels in people with diabetes. Physical activity helps muscles use glucose for energy and can lower blood sugar levels. Understanding the importance of regular exercise is key for effective diabetes management.

While keeping wounds covered is generally good advice to prevent infection, using antibiotic ointment on every wound is not necessary unless specifically advised by a healthcare professional. Proper wound care, including cleaning with mild soap and water, keeping the wound clean and dry, and seeking medical attention for any signs of infection

Referring the client to a social worker for support therapy is a good idea for ongoing emotional support and counseling. However, at this moment, the client might need immediate assistance

While relaxation techniques can be helpful in managing stress and anxiety, they might not address the immediate need for insulin administration education.

Explaining the importance of insulin, is crucial, but it may not be effective if the client is not in a receptive state.

This finding suggests a difference in peripheral pulses between the two lower extremities. While it could indicate arterial compromise, the question specifically asks about arterial obstruction at the site of the catheterization (right femoral artery).

This finding is concerning for arterial obstruction. Coolness, pallor, and blanching of the right foot indicate decreased arterial blood flow to the extremity. Arterial obstruction can lead to reduced perfusion distal to the occlusion site, resulting in these clinical signs.

These vital sign changes could indicate systemic complications, such as shock, rather than isolated arterial obstruction at the femoral artery site. While systemic changes can occur secondary to arterial obstruction, they are not specific indicators of obstruction at the femoral artery.

While having access to patient information is crucial, printing from a backup server might not be immediately feasible or necessary if the primary system is expected to be restored soon. The nurse should first notify IT services to resolve the issue. If access to patient records is urgently needed and cannot be delayed, then printing from a backup server could be considered after notifying IT services.C Waiting passively without taking action may delay the resolution of the issue. It's important for the nurse to proactively notify the information services department so they can begin troubleshooting and rebooting the system if necessary.

Correct choice is A
Rationale

Labeling information as a late entry should only be considered once the system is back online and accessible. It should be done according to facility policies and procedures regarding late entries in medical records. However, this should not be the first action because the primary concern is to restore the functionality of the computer documentation system.

Monitoring intake and output (I/O) is essential for assessing fluid balance, which is crucial in managing septic shock. Maintaining a strict I/O helps in determining fluid resuscitation needs and evaluating response to treatment. This intervention is important but may not be the most critical initially.

Assessing warmth of extremities is important as it helps in evaluating peripheral perfusion, which can be compromised in septic shock. Cold extremities can indicate poor tissue perfusion and may prompt the need for interventions such as fluid resuscitation.

Keeping the head of the bed elevated to 45 degrees is a specific intervention aimed at improving oxygenation and respiratory function, particularly in patients who may be mechanically ventilated or at risk of respiratory compromise. While this is an important intervention, it is not directly related to managing septic shock itself.

Knowing the client's current medications is important for understanding any potential causes or exacerbating factors related to the sudden onset of confusion and agitation. However, this is also background information and does not immediately address the acute change in the client's condition.

This is the most critical piece of information to provide first in the SBAR communication. Sudden onset of increasing confusion and agitation can indicate various urgent issues such as delirium, infection, metabolic disturbances, or neurological complications. This requires immediate attention and intervention from the healthcare provider.

While knowing the client's healthcare power of attorney is important for ensuring appropriate decision-making if needed, it is not urgent information in the context of reporting a sudden change in the client's condition. This can be discussed later in the SBAR communication or as part of the background information if relevant to the client's care.

Checking the femoral insertion site for hematoma formation is crucial after a cardiac catheterization. Hematomas can develop due to bleeding from the femoral artery puncture site, especially if the client is receiving anticoagulant therapy like heparin. A hematoma can compress surrounding structures, potentially causing pain and compromising circulation.

While it's important to assess the integrity of IV insertion sites, in this scenario, the primary concern is the groin insertion site used for cardiac catheterization. The IV insertion sites should be assessed regularly for signs of infiltration, phlebitis, or infection, but this should not take precedence over assessing the femoral insertion site for complications related to the procedure.

Deep breathing exercises are important for preventing respiratory complications such as atelectasis and pneumonia, especially in clients who are sedated and immobilized. However, in the context of acute pain at the femoral insertion site post-cardiac catheterization, assessing and addressing potential complications related to the procedure take priority.

Domestic violence assistance is crucial for community health and safety, but it is not typically categorized under primary disease prevention. Domestic violence is a social issue that requires interventions aimed at prevention and support for victims, rather than preventing diseases through health promotion and education.

Blood pressure screening is an example of a primary disease prevention activity. High blood pressure (hypertension) is a significant risk factor for cardiovascular diseases such as heart attack and stroke. By screening individuals for hypertension, nurses can identify those at risk early and provide education on lifestyle modifications or medical interventions to prevent cardiovascular disease.

Immunizations are a cornerstone of primary disease prevention. Vaccines prevent infectious diseases by stimulating the immune system to produce immunity against specific pathogens. Community outreach programs that educate the public about immunizations help increase vaccination rates, thereby reducing the incidence of vaccine-preventable diseases in the population.

Sequential compression stockings are used to prevent deep vein thrombosis (DVT) and promote circulation in clients undergoing surgery, particularly those with obesity who are at higher risk for venous thromboembolism. This intervention is important to prevent serious complications associated with immobility and surgery.

This option is not appropriate immediately after gastroplasty. Bariatric surgery, such as gastroplasty, typically involves restrictive procedures that limit the amount of food a person can consume. Providing a wide variety of meal choices contradicts the dietary restrictions and guidelines that are crucial for successful outcomes post-surgery.

While urinary incontinence can be a concern in some individuals, it is not directly related to bariatric surgery or the client's primary health concerns of obesity, diabetes mellitus, and hypertension. Monitoring for urinary incontinence may be important in other clinical contexts but is not a priority in the immediate postoperative period of gastroplasty.

This instruction is important because iodine-based contrast agents are commonly used during cystoscopy procedures to enhance visualization of the urinary tract. Clients with allergies to shellfish (due to potential cross-reactivity with iodine) or iodine itself should be identified to avoid allergic reactions. This allows the healthcare team to take appropriate precautions and possibly use alternative agents if needed.

This instruction is crucial for monitoring post-procedure complications. Painful urination, blood in urine (hematuria), and fever can indicate infection or other complications following a cystoscopy. Prompt reporting allows for early intervention and treatment if necessary.

This instruction is not typically necessary after a cystoscopy. Most clients can resume normal activities, including light exercise, shortly after the procedure. Avoiding strenuous activity for two weeks would be excessive and not aligned with typical post-cystoscopy recovery guidelines.

This instruction promotes a healthier dietary choice, as carbonated drinks often contain added sugars and contribute to excess calorie intake, which can contribute to obesity. However, fruit juices can also be high in sugars and should be consumed in moderation. Encouraging water as the primary beverage choice would be even better for weight loss and overall health.

This instruction is generally beneficial for maintaining joint mobility and preventing stiffness, which can be particularly important for someone experiencing pain in a weight-bearing joint like the ankle. However, if the pain is severe and acute, active range of motion exercises may need to be introduced gradually and under guidance to avoid exacerbating the condition.

Heat therapy can provide symptomatic relief for joint pain associated with conditions like gouty arthritis. However, it is important to ensure that heat is not applied during acute inflammation or gout flare-ups, as it can potentially worsen symptoms. Cold therapy may be more appropriate during active inflammation.

The positioning described (sitting forward with arms propped on a table) helps to expand the intercostal spaces and facilitates easier access to the pleural space during the procedure. The nurse should reinforce this position as appropriate for the thoracentesis procedure.

This statement is incorrect and would indicate a need for additional education. A persistent cough is not an expected outcome after a thoracentesis. While some clients may experience a mild cough during or immediately after the procedure due to irritation from the needle or local anesthesia, it should not persist afterwards.

This statement is generally correct. After a thoracentesis, it is recommended to limit strenuous activity and avoid heavy lifting for a day or two to minimize the risk of complications such as discomfort or injury at the needle insertion site. The nurse should support this instruction as part of the client's post-procedure care.

This instruction is unnecessary and overly restrictive. It is not typically required to keep a healthy infant home from daycare after receiving routine vaccinations. Most infants tolerate vaccines well and are not contagious from the vaccines themselves.

This instruction is overly cautious. Fever after vaccinations is common and usually mild. A low-grade fever (temperature over 100.4°F or 38°C) is a common side effect of vaccinations and can be managed with appropriate measures such as giving extra fluids and using acetaminophen if recommended by the healthcare provider.

Applying a cool pack directly to the injection site can help relieve discomfort to the injection skin. Instead, gentle comforting measures such as cuddling or applying a clean, cool cloth to the area may help soothe discomfort.

Placing the client in a high Fowler's position (sitting upright with the head of the bed elevated to 90 degrees) helps to maximize chest expansion and improve lung ventilation. This position can relieve dyspnea by reducing pressure on the diaphragm and improving lung compliance. It is a simple and effective intervention for clients experiencing respiratory distress.

While deep breathing exercises are beneficial for promoting lung expansion and improving respiratory function, they may not be appropriate as the first action when the client is already dyspneic. The priorityshould be to position the client to alleviate immediate breathing difficulty before initiating exercises that require active participation.

Auscultating breath sounds is important for assessing lung function and detecting any abnormalities such as adventitious sounds (e.g., crackles, wheezes). However, this action is secondary to placing the client in a high Fowler's position to relieve dyspnea. Auscultation can be performed after the client's breathing has stabilized.

This action is aimed at creating a quiet and calm environment for the client, which can help reduce anxiety and minimize stimuli that might exacerbate symptoms. Creating a conducive environment is beneficial for the client's comfort and well-being but should not delay urgent interventions required for acute symptoms.

PVCs are abnormal heartbeats that can occur in individuals with CAD and may indicate increased cardiac irritability or instability. While monitoring PVCs is important for assessing cardiac rhythm and potential complications, it is not the immediate priority over addressing acute symptoms such as shortness of breath, nausea, and chest pressure.

Oxygen therapy is essential in the management of a client with suspected ACS to improve oxygenation and reduce cardiac workload. Maintaining oxygen saturation above 93% helps ensure adequate tissue oxygenation, especially during episodes of chest discomfort and potential myocardial ischemia.

Pain scale is essential to evaluate the effectiveness of the equianalgesic dose. The nurse should ensure that the pain is adequately controlled with the IV dose comparable to what was achieved with the PO dose.

Blood pressure is monitored to detect any potential hypotensive effects of hydromorphone, particularly with IV administration.

Level of consciousness is assessed to ensure that the client is not overly sedated or experiencing other neurological side effects of the medication.

This option involves immediate action to provide hydration under close supervision. It implies that the nurse will closely monitor the client's ability to swallow and assess for signs of aspiration during the process. However, it does not address the underlying risk.

This option focuses on assessing the client's ability to swallow before providing more fluids. It acknowledges the potential danger of giving fluids without knowing the client's current swallowing ability, which could lead to aspiration.

Providing a straw might seem helpful but could potentially increase the risk of aspiration if the client has swallowing difficulties. It does not address the immediate need for assessing the client's ability to swallow safely.

Sending someone else to gather equipment may be necessary in some situations but does not address the current issue of the nurse preparing to irrigate with a luer-lock tipped syringe. This option delays addressing the immediate concern.

Applying povidone (such as povidone-iodine solution) to the site is a step in the preparation for aseptic technique but does not address the specific issue of the syringe type or the irrigation process itself.

Luer-lock syringes are commonly used for irrigation purposes because they securely attach to irrigation ports, preventing accidental disconnection during the procedure. Directing the nurse to attach the luer-lock syringe ensures that the irrigation can be performed safely and effectively.