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 :

🔹Neutrophils are key indicators of infection, especially in clients with burn wounds that are vulnerable to sepsis.

🔹A purulent discharge suggests potential wound infection, which is confirmed or monitored by tracking neutrophil levels as part of the white blood cell differential.

🔹Burn clients often have altered immune responses, so checking neutrophils ensures prompt recognition of infection progression.

🔹Early identification of systemic infection prevents sepsis, which is a major complication in full-thickness burns.

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Answer 2

Correct Answers:

Keep any wounds covered with an antibiotic ointment.

Rationale :

🔶 Diabetic clients must be proactive in wound care to prevent infection and complications such as diabetic foot ulcers.

🔶 Covering wounds with an antibiotic ointment and sterile dressing reduces bacterial growth and promotes healing.

🔶 Poor circulation and sensation in type 2 diabetes increase risk for unnoticed or untreated wounds.

🔶 This response reflects appropriate self-care and safety practices in managing chronic diabetes-related skin injuries.

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Answer 3

Correct Answers:

Leave the client's room and return later in the day.

Rationale :

🟢 The client's angry outburst signals denial or fear, which is a common early emotional response after a serious diagnosis.

🟢 Respecting the client’s emotional state preserves therapeutic communication and trust in future teaching sessions.

🟢 Teaching during high emotional distress is ineffective; delayed teaching supports better retention and cooperation.

🟢 This action honors patient autonomy and allows space for coping and emotional processing.

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Answer 4

Correct Answers:

Right foot is cool to the touch and appears pale and blanched.

Rationale :

💠This finding indicates arterial obstruction, potentially compromising perfusion to the extremity post-catheterization.

💠The cool temperature and pallor suggest impaired circulation due to possible clot or hematoma at the insertion site.

💠Prompt identification of ischemia signs is critical to preserve tissue integrity and prevent limb damage.

💠This is a vascular emergency that requires immediate intervention.

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Answer 5

Correct Answers:

Notify information services department of the situation.

Rationale :

🟡Prompt notification ensures timely technical support to restore the documentation system.

🟡Nursing documentation is a legal and clinical record, and system failure must be formally reported for patient safety and continuity of care.

🟡This initial step activates the IT team's response to correct the problem, minimizing disruption in care.

🟡Communication is essential to maintain electronic health record (EHR) integrity.

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Answer 6

Correct Answers:

Monitor blood glucose level.

Rationale :

⚫Sepsis causes metabolic changes, and stress-induced hyperglycemia is common—even in non-diabetics.

⚫Hyperglycemia worsens outcomes in sepsis by impairing immune response and healing.

⚫Monitoring blood glucose is part of early sepsis protocol to ensure tight glycemic control and reduce mortality.

⚫Elevated glucose may indicate poor tissue perfusion and ongoing systemic stress.

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Answer 7

Correct Answers:

Increasing confusion of the client.

Rationale :

🔴The first step in SBAR (Situation, Background, Assessment, Recommendation) is to identify the current concern.

🔴A sudden change in mental status post-ORIF suggests a potential fat embolism, which is an emergency.

🔴Early identification through effective SBAR improves communication and rapid intervention.

🔴This is the most urgent assessment finding that should be communicated first.

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Answer 8

Correct Answers:

Check femoral site for hematoma formation.

Rationale :

🔷Groin pain post-catheterization may indicate hematoma or bleeding at the insertion site.

🔷Hematoma formation can lead to vessel compression and compromised blood flow, requiring urgent management.

🔷Manual pressure or surgical intervention may be needed depending on the size and bleeding risk.

🔷Assessing the catheterization site ensures early detection of post-procedural complications.

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Answer 9

Correct Answers:

Immunizations that are available.

Rationale :

🟠Immunizations are a form of primary prevention, aiming to stop diseases before they occur.

🟠Community outreach promoting vaccination reduces population-level disease burden (e.g., measles, flu).

🟠This distinguishes from secondary or tertiary prevention, which focus on screening or managing disease.

🟠Teaching immunization supports proactive health behaviors.

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Answer 10

Correct Answers:

Apply sequential compression stockings.

Rationale :

🟣Bariatric clients post-gastroplasty are at increased risk for venous thromboembolism due to immobility and obesity.

🟣Sequential compression devices (SCDs) promote venous return and prevent clot formation.

🟣Early application of SCDs is a standard VTE prophylaxis intervention in post-bariatric surgery clients.

🟣Prevention of DVT and PE is critical in this population due to reduced mobility and high BMI.

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RN-HESI Exit~2025 Exam 4

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?

2 :
The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which response by the client indicates understanding?

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 :
The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

5 :
After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

6 :
The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

9 :
The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

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RN-HESI Exit~2025 Exam 4

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?

2 : The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which response by the client indicates understanding?

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 : The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

5 : After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

6 : The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

9 : The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

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?

2 :
The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which response by the client indicates understanding?

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 :
The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

5 :
After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

6 :
The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

9 :
The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?