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 (Ventolin HFA).
c. Ask about recent exposure to any new allergens or asthma triggers.
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 (Ventolin HFA).
c. Ask about recent exposure to any new allergens or asthma triggers.
