Question

A client is a 51-year-old male with pneumonia.

Answer 1

Correct Answers:

Supplemental oxygen 10 L/min via nasal cannula
Vital signs every 4 hours

Rationale :

Supplemental oxygen 10 L/min via nasal cannula

✍️Nasal cannulas are typically used for flow rates of 1–6 L/min.

✍️At higher rates (such as 10 L/min), they are ineffective and uncomfortable for the client.

✍️A simple face mask or non-rebreather mask is more appropriate for delivering 10 L/min of oxygen.

✍️This order contradicts the nurse’s action of applying a simple face mask, indicating inconsistency.

✍️Administering such a high flow rate via nasal cannula increases the risk of nasal mucosa dryness or trauma.

Vital signs every 4 hours

✍️The client has acute pneumonia, tachypnea (29 breaths/min), and low O₂ saturation (89%).

✍️These are signs of potential respiratory compromise, and this client needs more frequent monitoring than every 4 hours.

✍️The standard of care would involve vital signs at least every 1–2 hours until stabilized, especially after initiating high-flow oxygen therapy.

✍️This order does not reflect the acuity of the client's current condition.

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Answer 2

Correct Answers:

Perform hand hygiene
Identify the client using Z client identifiers
Check the skin around the face
Don gloves
Assess respiratory function

Rationale :

Perform hand hygiene

🎯 Hand hygiene is a critical infection control step that must be done before any patient interaction or equipment setup.

🎯 It helps prevent cross-contamination and infection during oxygen therapy application.

Identify the client using 2 client identifiers

🎯 Using two identifiers (e.g., name and date of birth) is essential to verify that the correct patient is receiving oxygen therapy.

🎯 This aligns with safe practice standards and avoids medication or treatment errors.

Check the skin around the face

🎯 Assessing facial skin ensures there are no pressure injuries, breakdown, or irritation before placing a face mask.

🎯 This helps prevent device-related skin damage, especially over bony areas like the nose and cheeks.

Don gloves

🎯 Gloves are recommended when handling respiratory equipment and when there is potential contact with secretions or mucous membranes.

🎯 This protects both the nurse and the client and follows standard precautions.

Assess respiratory function

🎯 A full respiratory assessment helps determine the urgency, effectiveness, and need for oxygen support.

🎯 Establishing baseline respiratory rate, SpO₂, and lung sounds is crucial for evaluating intervention success.

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Answer 3

Correct Answers

Blank 1 Correct Option: Tachypnea
Blank 2 Correct Option: Tachycardia

Rationale :

Tachypnea (Respiratory rate: 29 breaths/min)

🎯 Normal respiratory rate for adults is 12–20 breaths/min.

🎯 A respiratory rate of 29 indicates tachypnea, which is consistent with respiratory distress in pneumonia.

🎯 This is likely due to impaired gas exchange and increased work of breathing.

Tachycardia (Heart rate: 104 beats/min)

🎯 Normal adult heart rate is 60–100 beats/min.

🎯 A heart rate of 104 bpm reflects tachycardia, which may be a compensatory response to hypoxia or fever.

🎯 Common in pneumonia due to inflammatory response or decreased oxygen saturation (SpO₂ 89%).

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Answer 4

Correct Answers:

Assist the client in ambulating safely
Positioning the client with the head of the bed elevated
Teaching the client to cough at least once an hour

Rationale :

Assist the client in ambulating safely

💎 Early ambulation improves lung expansion and circulation, helping to prevent atelectasis and promote oxygenation.

💎 Movement facilitates mucus clearance and enhances overall respiratory function in pneumonia.

💎 Activity must be monitored for safety due to the client’s elevated heart and respiratory rates.

Positioning the client with the head of the bed elevated

💎 Elevating the head of the bed promotes diaphragmatic expansion and reduces the work of breathing.

💎 This position enhances alveolar ventilation and oxygen exchange in clients with respiratory compromise.

💎 It is a standard nursing intervention for optimizing oxygenation.

Teaching the client to cough at least once an hour

💎 Coughing helps mobilize secretions, clear airways, and reduce the risk of respiratory complications like consolidation or hypoxia.

💎 Hourly coughing improves ventilation-perfusion matching and promotes airway patency.

💎 This practice is crucial in managing pneumonia symptoms and improving oxygenation.

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Answer 5

Correct Answers

Rhonchi in the right lung [ Ineffective ]
Symmetric chest expansion [ Effective ]
Oxygen saturation greater than 94% [ Effective ]
PaCO2 55 mm Hg on a blood gas [ Ineffective ]
Client ambulates without shortness of breath [ Effective ]
Diminished breath sounds in the right lung [ Ineffective ]

Rationale :

Symmetric chest expansion

🎯 Indicates that both lungs are ventilating equally, suggesting improved lung mechanics and that oxygenation and ventilation are responding to treatment.

Oxygen saturation greater than 94%

🎯 Demonstrates effective oxygen supplementation and adequate gas exchange, achieving the target SpO₂ goal per orders.

Client ambulates without shortness of breath

🎯 Signifies improved functional status and respiratory stability, reflecting that interventions are relieving symptoms and improving endurance.

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Answer 6

Correct Answers:

Observe the client's fingers

Rationale :

🎯 Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease that primarily affects the small joints, especially the fingers, wrists, and hands, in its early stages.

🎯 The nurse should observe the client’s fingers for early signs such as:

Swelling
Redness
Deviation or joint deformity
Reduced range of motion
Morning stiffness

🎯 Detecting these subtle changes can lead to early diagnosis and treatment, which is essential in preventing permanent joint damage and maintaining function.

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Answer 7

Correct Answers:

Administer a stool softener.

Rationale :

🎯 After cataract extraction with lens implant, it is crucial to avoid activities that increase intraocular pressure (IOP).

🎯 Straining during bowel movements can elevate IOP, potentially leading to complications like hemorrhage or damage to the surgical site.

🎯 Using a stool softener helps prevent straining, promoting safe recovery.

🎯 Other standard precautions include avoiding bending over, heavy lifting, or vigorous coughing, all of which can increase IOP.

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Answer 8

Correct Answers:

Hematemesis

Rationale :

🎯 Esophageal varices are dilated veins in the esophagus caused by portal hypertension, a complication of chronic cirrhosis.

🎯 These fragile vessels can rupture easily, leading to life-threatening upper gastrointestinal bleeding.

🎯 Hematemesis (vomiting blood) is a critical sign of bleeding esophageal varices and requires immediate intervention.

🎯 Prompt recognition and management are essential to prevent hypovolemic shock and death.

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Answer 9

Correct Answers:

Prevent esophageal reflux.

Rationale :

🎯 A sliding hiatal hernia occurs when the upper part of the stomach slides through the esophageal hiatus of the diaphragm into the chest cavity, often leading to gastroesophageal reflux.

🎯 The main goal of nursing care is to prevent reflux of gastric contents into the esophagus, which can cause heartburn, esophagitis, or even Barrett’s esophagus if unmanaged.

🎯 Interventions may include elevating the head of the bed, advising small frequent meals, avoiding meals close to bedtime, and educating the client to avoid triggers like spicy foods or caffeine.

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Answer 10

Correct Answers:

Topical corticosteroids.

Rationale :

🎯 Psoriasis is a chronic autoimmune skin condition characterized by hyperproliferation of keratinocytes, resulting in silvery, scaly plaques often found on elbows, knees, and palms.

🎯 Topical corticosteroids are the first-line treatment for mild to moderate psoriasis because they reduce inflammation, itching, and plaque thickness.

🎯 They help relieve burning, bleeding, and discomfort, especially during flare-ups.

🎯 Stronger corticosteroids are typically used for thicker skin areas like palms and elbows.

🎯 Nurses should instruct clients on correct application, duration, and potential skin thinning with prolonged use.

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Options	Effective	Ineffective
Rhonchi in the right lung
Symmetric chest expansion
Oxygen saturation greater than 94%
PaCO2 55 mm Hg on a blood gas
Client ambulates without shortness of breath
Diminished breath sounds in the right lung

Hesi RN Adulth 1 Exam I

No.

1 :
A client is a 51-year-old male with pneumonia.

Answer Options

Supplemental oxygen 10 L/min via nasal cannula

Vital signs every 4 hours

2 :
A client is a 51-year-old male with pneumonia.

Answer Options

Perform hand hygiene

Identify the client using 2 client identifiers

Check the skin around the face

Don gloves

Assess respiratory function

3 :
A client is a 51-year-old male with pneumonia.

Correct Answers

Tachypnea (Respiratory rate: 29 breaths/min)

Tachycardia (Heart rate: 104 beats/min)

4 :
A client is a 51-year-old male with pneumonia.

Answer Options

Assist the client in ambulating safely

Positioning the client with the head of the bed elevated

Teaching the client to cough at least once an hour

5 :
A client is a 51-year-old male with pneumonia.

Correct Answers

Symmetric chest expansion

Oxygen saturation greater than 94%

Client ambulates without shortness of breath

6 :
A client is a 51-year-old male with pneumonia.

Answer Options

7 :
Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant?

8 :
A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?

9 :
The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?

10 :
A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

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Hesi RN Adulth 1 Exam I

No.

1 : A client is a 51-year-old male with pneumonia.

Answer Options

Supplemental oxygen 10 L/min via nasal cannula

Vital signs every 4 hours

2 : A client is a 51-year-old male with pneumonia.

Answer Options

Perform hand hygiene

Identify the client using 2 client identifiers

Check the skin around the face

Don gloves

Assess respiratory function

3 : A client is a 51-year-old male with pneumonia.

Correct Answers

Tachypnea (Respiratory rate: 29 breaths/min)

Tachycardia (Heart rate: 104 beats/min)

4 : A client is a 51-year-old male with pneumonia.

Answer Options

Assist the client in ambulating safely

Positioning the client with the head of the bed elevated

Teaching the client to cough at least once an hour

5 : A client is a 51-year-old male with pneumonia.

Correct Answers

Symmetric chest expansion

Oxygen saturation greater than 94%

Client ambulates without shortness of breath

6 : A client is a 51-year-old male with pneumonia.

Answer Options

7 : Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant?

8 : A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?

9 : The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?

10 : A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

1 :
A client is a 51-year-old male with pneumonia.

2 :
A client is a 51-year-old male with pneumonia.

3 :
A client is a 51-year-old male with pneumonia.

4 :
A client is a 51-year-old male with pneumonia.

5 :
A client is a 51-year-old male with pneumonia.

6 :
A client is a 51-year-old male with pneumonia.

7 :
Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant?

8 :
A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?

9 :
The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?

10 :
A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?