Question

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Answer 1

Correct Answers:

Neutrophil count.

Rationale :

🔸 Purulent drainage indicates a possible wound infection, which requires evaluation of the body’s immune response.

🔸 The neutrophil count is a direct indicator of acute bacterial infection and helps guide antimicrobial therapy.

🔸 Monitoring white blood cell components like neutrophils is critical in clients with extensive burns, as immunosuppression is common.

🔸 Neutrophilia (elevated neutrophils) typically correlates with active infection in burn clients.

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Answer 2

Correct Answers:

"After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, but it goes away."

Rationale :

🔸 The correct technique requires inhaling the medication, not swallowing it—swallowing indicates ineffective delivery to the lungs.

🔸 Improper use reduces the therapeutic effect and increases systemic absorption, causing side effects like nausea.

🔸 COPD clients must be reeducated on inhaler technique to ensure bronchodilation and symptom control.

🔸 The nurse should verify use of spacer, breath-hold, and coordination of actuation with inhalation.

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Answer 3

Correct Answers:

Explain that insulin is a life-saving drug for the client.

Rationale :

🔸 A client newly diagnosed with a chronic illness may experience denial or emotional distress, and this behavior signals a need for space and autonomy.

🔸 Leaving and returning later demonstrates respect, avoids confrontation, and allows the client time to process.

🔸 Forcing teaching during emotional outbursts may lead to ineffective learning and increased resistance.

🔸 Therapeutic communication includes recognizing and responding appropriately to client cues.

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Answer 4

Correct Answers:

A full pitcher of water is on the bedside table.
The client is lying in a supine position in bed.

Rationale :

A full pitcher of water is on the bedside table

Clients with heart failure must follow a fluid restriction to avoid volume overload, which worsens pulmonary congestion.
A full water pitcher at the bedside may encourage excessive fluid intake without the client or caregiver realizing it.
Fluid overload in heart failure can quickly escalate to acute decompensated heart failure, leading to respiratory distress.
Clients with COPD may already have compromised gas exchange, so added fluid exacerbates hypoxia.
Removing unnecessary water access helps support strict I/O monitoring.

The client is lying in a supine position in bed

Supine positioning reduces lung expansion and worsens dyspnea, especially in patients with COPD.
Patients with combined heart failure and COPD are at high risk of respiratory decompensation when flat.
Elevating the head of the bed promotes better alveolar ventilation and oxygenation.
Orthopnea is common in heart failure, so upright positioning is both comforting and clinically necessary.
Proper positioning can reduce the need for escalated oxygen support or ICU transfer.

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Answer 5

Correct Answers:

Pain scale.

Rationale :

🔷 Pain assessment is the most reliable way to evaluate whether the IV dose of hydromorphone is equivalent to the client’s previous PO dose.

🔷 A numeric or descriptive pain scale provides a subjective but standardized method to assess effectiveness.

🔷 Pain relief is a primary goal of opioid therapy, especially in clients with metastatic cancer.

🔷 Titrating to an equianalgesic dose requires ongoing assessment of pain intensity and relief patterns.

🔷 Evaluating pain allows the nurse to determine if adjustments in dose or frequency are necessary without causing over-sedation.

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Answer 6

Correct Answers:

Ask the spouse to stop and assess the client's swallowing reflex.

Rationale :

◾ Clients with stroke and facial paralysis often have dysphagia, putting them at high risk for aspiration.

◾ Assessing the swallowing reflex is a critical safety step before allowing any oral intake.

◾ Unchecked attempts at drinking may lead to aspiration pneumonia, a life-threatening complication.

◾ The nurse's role is to intervene appropriately when family members unknowingly put clients at risk.

◾ Swallow assessments help guide when to involve speech therapy or recommend NPO status.

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Answer 7

Correct Answers:

Assign the newly hired UAP to clients who require the least complex level of care.

Rationale :

🔴 Newly hired UAPs should be introduced gradually to ensure they can perform tasks safely and accurately.

🔴 Assigning less complex tasks aligns with the principles of safe delegation and avoids overwhelming the new staff.

🔴 This strategy protects patient safety while building the UAP’s confidence and experience.

🔴 Complex care requires critical thinking and familiarity, which may not yet be established in a new employee.

🔴 Appropriate task assignment helps the RN adhere to scope of practice guidelines and prevents legal issues.

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Answer 8

Correct Answers:

Relevance to the situation.

Rationale :

💠 In evidence-based practice, relevance ensures that research findings can be appropriately applied to the current clinical scenario.

💠 Evidence that lacks relevance may not address the patient’s specific condition, context, or values.

💠 Relevant evidence improves the accuracy and effectiveness of clinical decisions.

💠 The nurse must match clinical questions with evidence that directly informs practice.

💠 Prioritizing relevance supports client-centered care and improves outcomes.

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Answer 9

Correct Answers:

Apply a cool pack to the injection site to reduce discomfort.

Rationale :

🟣 A cool compress helps relieve pain, swelling, and redness at vaccine injection sites.

🟣 It is a safe, non-pharmacologic measure commonly recommended for infants after immunizations.

🟣 This strategy minimizes discomfort without interfering with vaccine efficacy.

🟣 Applying cool packs also decreases the need for unnecessary medications.

🟣 Teaching this to parents supports effective home care and reduces anxiety about side effects.

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Answer 10

Correct Answers:

Report any painful urination, blood in urine, or fever.

Rationale :

🔵 These symptoms may indicate post-procedure infection or trauma after a cystoscopy.

🔵 Prompt reporting ensures timely medical intervention to prevent complications.

🔵 Cystoscopy can cause minor irritation, but persistent or worsening symptoms suggest a problem.

🔵 Educating the client about signs of complications empowers them to seek care appropriately.

🔵 Infection prevention is a key post-procedure teaching point for any urologic intervention.

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RN HESI Exit~2024 Exam 2

No.

1 :
While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

3 :
When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

4 :
A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? Select all that apply.

5 :
A client with metastatic cancer who was taking hydromorphone PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?

7 :
A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?

9 :
A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines. Which instruction should the nurse provide the parent about care of the infant after the injections?

10 :
Which instruction should the nurse provide to a client who is preparing to have a cystoscopy?

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RN HESI Exit~2024 Exam 2

No.

1 : While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

3 : When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

4 : A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? Select all that apply.

5 : A client with metastatic cancer who was taking hydromorphone PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?

7 : A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?

9 : A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines. Which instruction should the nurse provide the parent about care of the infant after the injections?

10 : Which instruction should the nurse provide to a client who is preparing to have a cystoscopy?

1 :
While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

3 :
When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

4 :
A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? Select all that apply.

5 :
A client with metastatic cancer who was taking hydromorphone PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?

7 :
A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?

9 :
A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines. Which instruction should the nurse provide the parent about care of the infant after the injections?

10 :
Which instruction should the nurse provide to a client who is preparing to have a cystoscopy?