HESI RN Exit Exam 2023

HESI RN Exit Exam 2023 Related

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A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight-based heparin protocol are initiated. Which intervention is most important for the nurse to include in this client's plan of care?

  • A. Evaluate blood clotting factors daily.
  • B. Encourage incentive spirometry use.
  • C. Administer pain medication as needed.
  • D. Monitor for signs of bleeding.
Correct Answer: A

Rationale: Evaluating blood clotting factors daily is crucial when a client is on heparin therapy to monitor for potential complications such as bleeding or clotting issues. This monitoring helps ensure that the heparin dose is within the therapeutic range and reduces the risk of bleeding or clotting complications. Encouraging incentive spirometry use is beneficial for preventing atelectasis and improving lung function, but in this scenario, monitoring blood clotting factors takes precedence. Administering pain medication as needed is important for the client's comfort but is not the priority in managing a pulmonary embolism. Monitoring for signs of bleeding is important due to heparin therapy, but evaluating blood clotting factors provides more specific information on the client's response to treatment.

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A client with a tracheostomy has thick, tenacious secretions. Which intervention should the nurse implement first?

  • A. Perform deep suctioning every 2 to 4 hours.
  • B. Encourage the client to drink plenty of fluids.
  • C. Increase humidity in the client's room.
  • D. Administer a mucolytic agent.
Correct Answer: C

Rationale: Increasing humidity in the client's room can help liquefy thick secretions and facilitate easier airway clearance in a client with a tracheostomy. This intervention should be implemented first as it is non-invasive and can often effectively address the issue of thick secretions. Performing deep suctioning (Choice A) should not be the first intervention as it is more invasive and should be done based on assessment findings. Encouraging the client to drink plenty of fluids (Choice B) is beneficial but may not provide immediate relief for thick secretions. Administering a mucolytic agent (Choice D) requires a healthcare provider's prescription and should be based on assessment data and the client's condition.

The nurse is assessing a primigravida at 39-weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider?

  • A. Fetal heart rate of 200 beats/minute.
  • B. Mild ankle edema.
  • C. Complaints of back pain.
  • D. Decreased fetal movements.
Correct Answer: A

Rationale: A fetal heart rate of 200 beats per minute is significantly elevated and requires immediate medical attention. This finding could indicate fetal distress, tachycardia, or other serious issues that need prompt evaluation. Mild ankle edema, complaints of back pain, and decreased fetal movements are common in pregnancy but are not as urgent or concerning as a high fetal heart rate.

Following discharge teaching, a male client with a duodenal ulcer tells the nurse he will drink plenty of dairy products to help coat and protect his ulcer. What is the best follow-up action by the nurse?

  • A. Remind the client that it is also important to switch to decaffeinated coffee and tea.
  • B. Suggest that the client also plans to eat frequent small meals to reduce discomfort.
  • C. Review with the client the need to avoid foods that are rich in milk and cream.
  • D. Reinforce this teaching by asking the client to list a dairy food that he might select.
Correct Answer: C

Rationale: The correct answer is C because diets rich in milk and cream stimulate gastric acid secretion, which can exacerbate a duodenal ulcer. Therefore, it is essential to avoid foods that are rich in milk and cream. Choice A is incorrect because switching to decaffeinated coffee and tea does not address the issue of avoiding milk and cream products. Choice B is incorrect because while eating frequent small meals can help with discomfort, it does not address the specific issue of avoiding milk and cream. Choice D is incorrect as it does not address the need to avoid milk and cream products.

The practical nurse (PN) is assigned to work with three registered nurses (RNs) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN?

  • A. Diabetic ketoacidosis with a Glasgow Coma Scale score change from 10 to 7.
  • B. Myxedema coma with a blood pressure change from 80/50 to 70/40.
  • C. Viral meningitis with a temperature change from 101°F to 102°F.
  • D. Subdural hematoma with a blood pressure change from 150/80 to 170/60.
Correct Answer: C

Rationale: The client with viral meningitis and a temperature change is the most stable and appropriate for assignment to the PN. A change in temperature from 101°F to 102°F is not as critical as changes in Glasgow Coma Scale score, blood pressure, or wider blood pressure variations. The other clients require more complex monitoring and intervention due to their critical changes in status.

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which laboratory value should be monitored closely?

  • A. Arterial blood gas (ABG) values
  • B. Serum potassium level
  • C. Serum sodium level
  • D. Serum magnesium level
Correct Answer: B

Rationale: The correct answer is B: Serum potassium level. In COPD, especially when the client is receiving diuretics or corticosteroids, monitoring serum potassium levels is crucial. These medications can lead to potassium loss, potentially causing hypokalemia. Arterial blood gas (choice A) values are important in assessing respiratory status but are not the primary concern related to medication side effects. Serum sodium (choice C) and magnesium (choice D) levels are also important, but in the context of COPD exacerbation and medication effects, potassium monitoring takes precedence.

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