HESI Critical Care Exam HESI Critical Care Exam HESI Critical Care Exam HESI Critical Care Exam HESI Critical Care Exam HESI Critical Care Exam HESI Critical Care Exam HESI Critical Care Exam HESI Critical Care Exam HESI Critical Care Exam HESI Critical Care Exam HESI Critical Care Exam HESI Critic...
A 56-year-old female client is receiving intracavitary radiation via a radium implant.
Which
nurse should be assigned to care for this client?
A. The nurse who is caring for another client receiving intracavitary radiation.
B. A nurse with Marfan's syndrome who is postmenopausal.
C. A nurse with oncology experience who may be pregnant.
D. The nurse who is caring for another client who has Clostridium difficile.
✓ ~~~ B. A nurse with Marfan's syndrome who is postmenopausal.
✓ RATIONALE:
✓ A client receiving intracavity radiation poses a radiation hazard as long as the intracavity
✓ radiation source is in place. A nurse's ability to care of this client is not affected by
Marfan's
✓ syndrome (B), which is a hereditary disorder of connective tissues, bones, muscles,
ligaments
✓ and skeletal structures. The goal is to limit any one staff member's exposure to the
calculated
✓ time span based on the half-life of radium, such as the number of minutes at the bedside
per day,
✓ so (A) should not be assigned. (C) should not be exposed to the radiation due to the
possible
✓ effect on the fetus. A radiation exposure decreases the immune response in the client
who should
✓ not be exposed to the potential inadvertent transmission of an infectious organism (D).
1.A client who has active tuberculosis (TB) is admitted to the medical unit. What
action is most
important for the nurse to implement?
A. Fit the client with a respirator mask.
,B. Assign the client to a negative air-flow room.
C. Don a clean gown for client care.
D. Place an isolation cart in the hallway
✓ ~~~ Assign the client to a negative air-flow room
RATIONALE:
Active tuberculosis requires implementation of airborne precautions, so the client
should be
assigned to a negative pressure air-flow room (D). Although (A and C) should be
implemented
for clients in isolation with contact precautions, it is most important that air flow from
the room
is minimized when the client has TB. (B) should be implemented when the client
leaves the
isolation environment.
2.A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction.
The nurse
determines the client's apical pulse is 65 beats per minute. What action should the
nurse
implement
next?
A. Measure the blood pressure.
,B. Reassess the apical pulse.
C. Notify the healthcare provider.
D. Administer the medication.
✓ ~~~ Administer the medication
RATIONALE:
Atenolol, a beta-blocker, blocks the beta receptors of the sinoatrial node to reduce
the heart rate,
so the medication should be administered (C) because the client's apical pulse is
greater than 60.
(A, B, and D) are not indicated at this time.
3.The nurse is assessing a client and identifies a bruit over the thyroid. This finding is
consistent
with which interpretation?
A. Hypothyroidism.
B. Thyroid cyst.
C. Thyroid cancer.
D. Hyperthyroidism
✓ ~~~ Hyperthyroidism
Rationale:Hyperthyroidism (D) is an enlargement of the thyroid gland, often referred
to as a goiter, and a
, bruit may be auscultated over the goiter due to an increase in glandular vascularity
which
increases as the thyroid gland becomes hyperactive. A bruit is not common with (A,
B, and C).
A 6-year-old child is alert but quiet when brought to the emergency center with
periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects
potential child abuse and continues to assess the child for additional manifestations
of a basilar skull fracture. What
assessment finding would be consistent with a basilar skull fracture?
A. Hematemesis and abdominal distention.
B. Asymmetry of the face and eye movements.
C. Rhinorrhoea or otorrhoea with Halo sign.
D. Abnormal position and movement of the arm.
✓ ~~~ Rhinorrhoea or otorrhoea with Halo sign.
RATIONALE:
Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear
over the
mastoid process) are both signs of a basilar skull fracture, so the nurse should
assess for possible
meningeal tears that manifest as a Halo sign with CSF leakage from the ears or
nose (D). (A) is
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