RN HESI Exit Exam

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A 46-year-old male client who had a myocardial infarction 24 hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?

  • A. Ineffective coping related to denial.
  • B. Risk for impaired cardiac function.
  • C. Noncompliance related to lack of knowledge.
  • D. Anxiety related to hospitalization.
Correct Answer: A

Rationale: The correct answer is A: Ineffective coping related to denial. The client's desire to leave the hospital shortly after a myocardial infarction despite the severity of the condition indicates denial and ineffective coping. This behavior could lead to complications as the client may not adequately address his health needs. Choice B, Risk for impaired cardiac function, is not the most appropriate nursing problem in this scenario as the client's behavior is more indicative of psychological coping issues rather than a direct physiological risk at this moment. Choice C, Noncompliance related to lack of knowledge, does not align with the client's behavior of wanting to leave the hospital. Choice D, Anxiety related to hospitalization, may not be the best option as the client's behavior is more suggestive of denial rather than anxiety about being hospitalized.

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The nurse is caring for a client with a chest tube in place following a pneumothorax. Which finding requires immediate intervention?

  • A. Oxygen saturation of 95%
  • B. Crepitus around the insertion site
  • C. Subcutaneous emphysema
  • D. Drainage of 50 ml per hour
Correct Answer: C

Rationale: Subcutaneous emphysema requires immediate intervention in a client with a chest tube following a pneumothorax as it can indicate a pneumothorax recurrence or air leak. Oxygen saturation of 95% is within the normal range and does not require immediate intervention. Crepitus around the insertion site can be expected post-procedure and may not necessitate immediate action. Drainage of 50 ml per hour is a normal finding and does not raise immediate concerns.

The nurse is assessing a client with left-sided heart failure. Which finding is most concerning?

  • A. Jugular venous distention
  • B. Crackles in the lungs
  • C. Shortness of breath
  • D. Peripheral edema
Correct Answer: C

Rationale: Shortness of breath is most concerning in a client with left-sided heart failure as it indicates pulmonary congestion, requiring immediate intervention. Jugular venous distention (Choice A) is a sign of increased central venous pressure but is not as concerning as pulmonary congestion. Crackles in the lungs (Choice B) are common in heart failure due to fluid accumulation but are not as immediately concerning as severe shortness of breath. Peripheral edema (Choice D) is a manifestation of fluid retention in the body but is less indicative of acute pulmonary distress compared to shortness of breath.

The nurse is reviewing a client's electrocardiogram and determines the PR interval (PRI) is prolonged. What does this finding indicate?

  • A. Initiation of the impulses from a location outside the SA node
  • B. Inability of the SA node to initiate an impulse at the normal rate
  • C. Increased conduction time from the SA node to the AV junction
  • D. Interference with the conduction through one or both ventricles
Correct Answer: C

Rationale: When the PR interval is prolonged, it signifies an increased conduction time from the SA node through the AV junction. This finding is characteristic of a first-degree heart block where there is a delay in the electrical conduction at the level of the AV node. Choices A, B, and D are incorrect as they do not accurately reflect the significance of a prolonged PR interval.

The nurse is assessing a 1-year-old child with bronchiolitis caused by respiratory syncytial virus (RSV). Which assessment finding requires immediate intervention?

  • A. Wheezing heard on expiration
  • B. Oxygen saturation of 90%
  • C. Respiratory rate of 40 breaths per minute
  • D. Nasal flaring with sternal retractions
Correct Answer: D

Rationale: Nasal flaring with sternal retractions indicates severe respiratory distress in a 1-year-old with bronchiolitis, requiring immediate intervention. Nasal flaring and sternal retractions are signs of increased work of breathing and decreased air movement, indicating the child is struggling to breathe. Wheezing on expiration (Choice A) is common in bronchiolitis but may not require immediate intervention. An oxygen saturation of 90% (Choice B) is low but may not be the most critical finding in this case. A respiratory rate of 40 breaths per minute (Choice C) is elevated but alone may not indicate the need for immediate intervention as much as nasal flaring and sternal retractions.

A client with a history of chronic heart failure is admitted with shortness of breath and crackles in the lungs. Which intervention should the nurse implement first?

  • A. Administer oxygen therapy as prescribed.
  • B. Administer a loop diuretic as prescribed.
  • C. Administer intravenous morphine as prescribed.
  • D. Obtain an arterial blood gas (ABG) sample.
Correct Answer: A

Rationale: Administering oxygen therapy is the priority intervention for a client with chronic heart failure presenting with shortness of breath and crackles in the lungs. Oxygen therapy helps improve oxygenation, which is crucial in managing respiratory distress. Loop diuretics (Choice B) may be indicated to manage fluid overload in heart failure but are not the immediate priority in this case. Administering morphine (Choice C) is not the first-line intervention for shortness of breath in heart failure and should be considered after addressing oxygenation and underlying causes. Obtaining an arterial blood gas sample (Choice D) can provide valuable information but is not the initial action needed to address the client's acute respiratory distress.

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