HESI Practice Exam

Which assessment is most important for the nurse to perform on a client who is hospitalized for Guillain-Barre syndrome that is rapidly progressing? Respiratory effort. Unsteady gait. Intensity of pain. Ability to eat. - Correct Answer-Respiratory effort. Guillain-Barre syndrome causes paralysis or weakness that typically starts at the feet and progresses upwards. As the condition progresses, the nurse must ensure that the client is able to breathe effectively. A male client comes into the clinic with a history of penile discharge with painful, burning urination. Which action should the nurse implement? Collect a culture of the penile discharge. Palpate the inguinal lymph nodes gently. Observe for scrotal swelling and redness. Express the discharge to determine color. - Correct Answer-Collect a culture of the penile discharge. Penile discharge with painful urination is commonly associated with gonorrhea. The nurse should collect a culture of the penile discharge to determine the cause of these symptoms. The cause must be determined or confirmed through culture to identify the organism and ensure effective treatment. A client with history of atrial fibrillation is admitted to the telemetry unit with sudden onset of shortness of breath. The nurse observes a new irregular heart rhythm and should perform which assessment at this time? Check for a pulse deficit. Palpate the apical impulse. Inspect jugular vein pulse. Examine for a carotid bruit. - Correct Answer-Check for a pulse deficit.