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HESI RN Exit Exam IV Share this
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Answer and Explanation
Question 1: Report an Issue
Report Wrong Answer
Choice A:
Although low serum albumin levels can
While caring for a client with a full impact wound healing, they are not
thickness burn covering 40% of the directly related to the presence of purulent
body surface area (BSA), the nurse drainage.
observes purulent drainage at the
wound. Before reporting this finding Choice B:
to the healthcare provider, the
nurse should note which of the Neutrophils are a type of white blood cell
client's laboratory values? involved in the body's immune response,
particularly against bacterial infections. An
A. Serum albumin. 27% elevated neutrophil count (neutrophilia)
B. Neutrophil count. 61% can indicate an acute infection or
Most selected inflammation, including in wounds.
C. Serum blood glucose (BG) level.
Choice C:
5%
High blood glucose levels can predispose
D. Hematocrit. 5%
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.
Choice D:
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.
Discussion Section
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Answer and Explanation
Question 2: Report an Issue
Report Wrong Answer Choice A:
Correct choice is B
The nurse is providing teaching to a Rationale
client with type 2 diabetes mellitus A This statement is incorrect for diabetes
about important points for disease and management. People with diabetes should avoid
symptom management. Which soaking their feet in hot water, as it can lead to
response by the client indicates burns and skin damage, which is particularly
understanding? risky due to potential nerve damage (neuropathy)
A. Soak feet daily in hot water no and poor circulation common in diabetes.
longer than 10 minutes. 0%
B. Include no more than 1-2 Choice B:
alcoholic beverages in diet per day. This statement demonstrates good
33% understanding. Alcohol can affect blood sugar
levels and should be consumed in moderation by
C. Remember exercise will not
people with diabetes. Limiting intake to 1-2
affect blood glucose levels. 22%
drinks per day (following healthcare provider's
D. Keep any wounds covered with advice) is generally recommended to minimize
an antibiotic ointment. 44% the impact on blood sugar levels and overall
Most selected health.
Choice C:
, 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.
Choice D:
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
Discussion Section
M Share insights...
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Answer and Explanation
Question 3: Report an Issue
Report Wrong Answer
Choice A:
This allows the client time to process their
When the nurse attempts to teach self- emotions. A diagnosis with a chronic illness can
administration of insulin injections to a be overwhelming.
client who is newly diagnosed with
type 1 diabetes mellitus (DM), the Choice B:
client tells the nurse in a loud voice to
Referring the client to a social worker for support
leave the room. Which action should therapy is a good idea for ongoing emotional
the nurse take? support and counseling. However, at this
A. Leave the client's room and
moment, the client might need immediate
return later in the day. 70% assistance
Most selected
B. Refer client to the social worker Choice C:
for support therapy. 5% While relaxation techniques can be helpful in
managing stress and anxiety, they might not
C. Encourage client to implement
address the immediate need for insulin
relaxation techniques. 11%
administration education.
, D. Explain that insulin is a life- Choice D:
saving drug for the client. 11% Explaining the importance of insulin, is crucial,
but it may not be effective if the client is not in a
receptive state.
Discussion Section
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Answer and Explanation
Question 4: Report an Issue
Report Wrong Answer Choice A:
While bleeding can occur postoperatively
The nurse is caring for a 3-year-old from the catheter insertion site, it is more
client who is two hours indicative of venous or capillary bleeding
postoperative from a cardiac rather than arterial obstruction. Arterial
catheterization via the right obstruction typically presents with signs
femoral artery. Which assessment related to decreased arterial blood flow
finding is an indication of arterial rather than external bleeding.
obstruction?
A. The pressure dressing at right Choice B:
femoral area is moist and oozing This finding suggests a difference in
blood. 6% peripheral pulses between the two lower
B. Pulse distal to the femoral artery extremities. While it could indicate arterial
is weaker on left foot than right compromise, the question specifically asks
foot. 0% about arterial obstruction at the site of the
catheterization (right femoral artery).
C. Right foot is cool to the touch
and appears pale and blanched.
Choice C:
86% Most selected
This finding is concerning for arterial
D. Blood pressure trend is
obstruction. Coolness, pallor, and
downward and pulse is rapid and
blanching of the right foot indicate
irregular. 6%
decreased arterial blood flow to the
extremity. Arterial obstruction can lead to
reduced perfusion distal to the occlusion
site, resulting in these clinical signs.
Choice D:
HESI RN Exit Exam IV Share this
We are excited to announce the release of a NEW VERSION OF THE SYSTEM! To benefit from the
latest features, improvements, and component updates, please switch to the new system as soon
as possible.
Visit Latest Version
Answer and Explanation
Question 1: Report an Issue
Report Wrong Answer
Choice A:
Although low serum albumin levels can
While caring for a client with a full impact wound healing, they are not
thickness burn covering 40% of the directly related to the presence of purulent
body surface area (BSA), the nurse drainage.
observes purulent drainage at the
wound. Before reporting this finding Choice B:
to the healthcare provider, the
nurse should note which of the Neutrophils are a type of white blood cell
client's laboratory values? involved in the body's immune response,
particularly against bacterial infections. An
A. Serum albumin. 27% elevated neutrophil count (neutrophilia)
B. Neutrophil count. 61% can indicate an acute infection or
Most selected inflammation, including in wounds.
C. Serum blood glucose (BG) level.
Choice C:
5%
High blood glucose levels can predispose
D. Hematocrit. 5%
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.
Choice D:
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.
Discussion Section
M Share insights...
1 Pulse Check
JOY: well understood with a better understanding ~ 3mos ago
0 0 Reply
Answer and Explanation
Question 2: Report an Issue
Report Wrong Answer Choice A:
Correct choice is B
The nurse is providing teaching to a Rationale
client with type 2 diabetes mellitus A This statement is incorrect for diabetes
about important points for disease and management. People with diabetes should avoid
symptom management. Which soaking their feet in hot water, as it can lead to
response by the client indicates burns and skin damage, which is particularly
understanding? risky due to potential nerve damage (neuropathy)
A. Soak feet daily in hot water no and poor circulation common in diabetes.
longer than 10 minutes. 0%
B. Include no more than 1-2 Choice B:
alcoholic beverages in diet per day. This statement demonstrates good
33% understanding. Alcohol can affect blood sugar
levels and should be consumed in moderation by
C. Remember exercise will not
people with diabetes. Limiting intake to 1-2
affect blood glucose levels. 22%
drinks per day (following healthcare provider's
D. Keep any wounds covered with advice) is generally recommended to minimize
an antibiotic ointment. 44% the impact on blood sugar levels and overall
Most selected health.
Choice C:
, 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.
Choice D:
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
Discussion Section
M Share insights...
0 Pulse Checks
No comments
Answer and Explanation
Question 3: Report an Issue
Report Wrong Answer
Choice A:
This allows the client time to process their
When the nurse attempts to teach self- emotions. A diagnosis with a chronic illness can
administration of insulin injections to a be overwhelming.
client who is newly diagnosed with
type 1 diabetes mellitus (DM), the Choice B:
client tells the nurse in a loud voice to
Referring the client to a social worker for support
leave the room. Which action should therapy is a good idea for ongoing emotional
the nurse take? support and counseling. However, at this
A. Leave the client's room and
moment, the client might need immediate
return later in the day. 70% assistance
Most selected
B. Refer client to the social worker Choice C:
for support therapy. 5% While relaxation techniques can be helpful in
managing stress and anxiety, they might not
C. Encourage client to implement
address the immediate need for insulin
relaxation techniques. 11%
administration education.
, D. Explain that insulin is a life- Choice D:
saving drug for the client. 11% Explaining the importance of insulin, is crucial,
but it may not be effective if the client is not in a
receptive state.
Discussion Section
M Share insights...
0 Pulse Checks
No comments
Answer and Explanation
Question 4: Report an Issue
Report Wrong Answer Choice A:
While bleeding can occur postoperatively
The nurse is caring for a 3-year-old from the catheter insertion site, it is more
client who is two hours indicative of venous or capillary bleeding
postoperative from a cardiac rather than arterial obstruction. Arterial
catheterization via the right obstruction typically presents with signs
femoral artery. Which assessment related to decreased arterial blood flow
finding is an indication of arterial rather than external bleeding.
obstruction?
A. The pressure dressing at right Choice B:
femoral area is moist and oozing This finding suggests a difference in
blood. 6% peripheral pulses between the two lower
B. Pulse distal to the femoral artery extremities. While it could indicate arterial
is weaker on left foot than right compromise, the question specifically asks
foot. 0% about arterial obstruction at the site of the
catheterization (right femoral artery).
C. Right foot is cool to the touch
and appears pale and blanched.
Choice C:
86% Most selected
This finding is concerning for arterial
D. Blood pressure trend is
obstruction. Coolness, pallor, and
downward and pulse is rapid and
blanching of the right foot indicate
irregular. 6%
decreased arterial blood flow to the
extremity. Arterial obstruction can lead to
reduced perfusion distal to the occlusion
site, resulting in these clinical signs.
Choice D:
