7. Which assessment finding in a patient who has received omalizumab (Xolair) is most important to report
immediately to the health care provider?
a. Pain at injection site c. Peak flow reading 75% of normal
b. Flushing and dizziness d. Respiratory rate 24 breaths/minute
ANS: B
Flushing and di...
HESI RN COMPREHENSIVE PREDICTOR EXAM
37.Which assessment finding in a patient who has received omalizumab (Xolair) is most important to report
immediately to the health care provider?
a.Pain at injection site c. Peak flow reading 75% of normal
b.Flushing and dizziness d. Respiratory rate 24 breaths/minute
ANS: B
Flushing and dizziness may indicate that the patient is experiencing an anaphylactic reaction, and immediate
intervention is needed. The other information should also be reported, but do not indicate possibly life- threatening complications of omalizumab therapy.
38.The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. The results for which patient will require the most rapid action by
the nurse?
a.pH 7.28, PaCO2 50 mm Hg, and PaO2 58 mm Hg
b.pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg
c.pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg
d.pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg
ANS: A
The pH, PaCO2, and PaO2 indicate that the patient has severe uncompensated respiratory acidosis and
hypoxemia. Rapid action will be required to prevent increasing hypoxemia and correct the acidosis.
OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients
39.Which nursing action for a patient with chronic obstructive pulmonary disease (COPD) could the nurse
delegate to experienced unlicensed assistive personnel (UAP)?
a.Obtain O2 saturation using pulse oximetry.
b.Monitor for increased O2 need with exercise.
c.Teach the patient about safe use of O2 at home.
d.Adjust O2 to keep saturation in prescribed parameters.
ANS: A
UAP can obtain O2 saturation (after being trained and evaluated in the skill). The other actions require
more education and a scope of practice that licensed practical/vocational nurses (LPN/LVNs) or registered
nurses (RNs) would have.
OBJ: Special Questions: Delegation 40. The clinic nurse makes a follow-up telephone call to a patient with asthma. The patient reports having a baseline peak flow reading of 600 L/min, and the current peak flow is 420 L/min. Which action should the nurse take first?
a.Tell the patient to go to the hospital emergency department.
b.Instruct the patient to use the prescribed albuterol (V entolin HFA).
c.Ask about recent exposure to any new allergens or asthma triggers. d.Question the patient about use of the prescribed inhaled corticosteroids.
ANS: B
The patient’s peak flow is 70% of normal, indicating a need for immediate use of short-acting b2-adrenergic SABA medications. Assessing for correct use of medications or exposure to allergens is also appropriate, but would not address the current decrease in peak flow. Because the patient is currently in the yellow zone, hospitalization is not needed.
OBJ: Special Questions: Prioritization 41. The nurse reviews the medication administration record (MAR) for
a patient having an acute asthma attack. Which medication should the nurse administer first?
a.Methylprednisolone (Solu-Medrol) 60 mg IV
b.Albuterol (Ventolin HFA) 2.5 mg per nebulizer
c.Salmeterol (Serevent) 50 mcg per dry-powder inhaler (DPI)
d.Ipratropium (Atrovent) 2 puffs per metered-dose inhaler (MDI)
ANS: A
Albuterol is a rapidly acting bronchodilator and is the first-line medication to reverse airway narrowing in
acute asthma attacks. The other medications work more slowly.
OBJ: Special Questions: Prioritization 42. The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first?
a.A patient with loud expiratory wheezes
b.A patient with a respiratory rate of 38 breaths/min
c.A patient who has a cough productive of thick, green mucus
d.A patient with jugular venous distention and peripheral edema
ANS: B
A respiratory rate of 38/min indicates severe respiratory distress, and the patient needs immediate assessment and intervention to prevent possible respiratory arrest. The other patients also need assessment as soon as possible, but they do not need to be assessed as urgently as the patient with tachypnea.
OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients
43. Which finding in a patient hospitalized with bronchiectasis is most important to report to the health care provider?
a.Cough productive of bloody, purulent mucus
b.Scattered crackles and wheezes heard bilaterally
c.Complaint of sharp chest pain with deep breathing
d.Respiratory rate 28 breaths/minute while ambulating
ANS: A Hemoptysis may indicate life-threatening hemorrhage, and should be reported immediately to the health care provider. The other findings are frequently noted in patients with bronchiectasis and may need further assessment but are not indicators of life-threatening complications.
COMPLETION
ALL HESI LINKS A V AILABLE
HESI PN MATERNAL NEWBERN OB EXAM (4
VERSIONS) / PN HESI MATERNAL NEWBERN OB
EXAM (LATEST-2021): (ANSWERS VERIFIED 100%
CORRECT)
https://www.stuvia.com/doc/1032238/hesi-pn-maternal-newbern-ob-exam-4-versions-pn-hesi-
maternal-newbern-ob-exam-latest-2021-answers-verified-100-correct
HESI RN LEADERSHIP PROCTORED EXAM ( 11
VERSIONS) / RN HESI LEADERSHIP PROCTORED
EXAM(LATEST-2021): (ANSWERS VERIFIED 100%
CORRECT)
https://www.stuvia.com/doc/1032243/hesi-rn-leadership-proctored-exam-11-versions-rn-hesi-
leadership-proctored-examlatest-2021-answers-verified-100-correct
HESI COMMUNITY HEALTH PROCTORED EXAM
(13 VERSIONS) / COMMUNITY HEALTH HESI
PROCTORED EXAM(LATEST-2021): (ANSWERS
VERIFIED 100% CORRECT)
https://www.stuvia.com/doc/1032247/hesi-community-health-proctored-exam-13-versions-
community-health-hesi-proctored-examlatest-2021-answers-verified-100-correct
HESI COMPREHENSIVE EXIT EXAM (14
VERSIONS) / COMPREHENSIVE HESI EXIT 205
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