HESI RN Exit Exam

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A client with severe COPD is receiving oxygen therapy at 2 liters per minute via nasal cannula. The client's oxygen saturation level drops to 88% during ambulation. What action should the nurse take first?

  • A. Increase the oxygen flow rate to 4 liters per minute.
  • B. Instruct the client to rest until the oxygen saturation improves.
  • C. Discontinue ambulation and return the client to bed.
  • D. Encourage the client to breathe more deeply.
Correct Answer: C

Rationale: In this scenario, the client's oxygen saturation level dropping during ambulation indicates an inadequate oxygen supply. The first action the nurse should take is to discontinue ambulation and return the client to bed. This helps stabilize the oxygen level by reducing the oxygen demand placed on the client during physical activity. Increasing the oxygen flow rate without addressing the underlying issue of oxygen saturation dropping may not be effective. Instructing the client to rest is not enough to address the immediate need for stabilization of oxygen levels. Encouraging the client to breathe more deeply may not be sufficient to overcome the oxygen saturation drop caused by inadequate oxygen supply during ambulation.

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The nurse is caring for a client who is postoperative following a thyroidectomy. Which laboratory value should be monitored closely?

  • A. Serum calcium of 8.5 mg/dL
  • B. Serum sodium of 136 mEq/L
  • C. Serum potassium of 3.0 mEq/L
  • D. Serum chloride of 102 mEq/L
Correct Answer: C

Rationale: A serum potassium level of 3.0 mEq/L should be monitored closely in a client who is postoperative following a thyroidectomy to detect any electrolyte imbalances. After a thyroidectomy, there is a risk of hypokalemia due to the effects of anesthesia, stress response, and the surgical procedure itself. Monitoring serum potassium levels is crucial as hypokalemia can lead to cardiac arrhythmias and muscle weakness. Serum calcium, sodium, and chloride levels are important but not the primary focus following a thyroidectomy, making them incorrect choices.

After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first?

  • A. Slide the stethoscope across the sternum.
  • B. Move the stethoscope to the mitral site.
  • C. Listen with the bell at the same location.
  • D. Observe the cardiac telemetry monitor.
Correct Answer: C

Rationale: The nurse uses the bell of the stethoscope to hear low-pitched sounds such as S3 and S4. To determine if an S3 heart sound is present, the nurse should listen at the same location using the bell first. This allows for the accurate identification of low-pitched sounds. Moving the stethoscope across the sternum (Choice A) or to the mitral site (Choice B) would not be the initial actions to assess for an S3 heart sound. Observing the cardiac telemetry monitor (Choice D) is not relevant for assessing S3 heart sounds, as it does not provide direct auscultation of heart sounds.

A client with chronic obstructive pulmonary disease (COPD) is experiencing shortness of breath and has a prescription for oxygen therapy. What is the maximum amount of oxygen the nurse should administer without a healthcare provider's order?

  • A. 2 liters per minute
  • B. 4 liters per minute
  • C. 6 liters per minute
  • D. 8 liters per minute
Correct Answer: B

Rationale: The correct answer is 4 liters per minute. Without a healthcare provider's order, the nurse should administer a maximum of 4 liters per minute of oxygen to prevent carbon dioxide retention in COPD clients. Higher flow rates can lead to oxygen toxicity and worsen the client's condition. Choices A, C, and D exceed the safe limit for oxygen administration without a healthcare provider's order.

The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour?

  • A. 50 ml/hour
  • B. 25 ml/hour
  • C. 75 ml/hour
  • D. 100 ml/hour
Correct Answer: C

Rationale: To calculate the infusion rate, convert 1 mg to 1,000 mcg (1 mg = 1,000 mcg) and then use the formula D/H x Q, where D is the desired dose, H is the dose on hand, and Q is the quantity of solution. In this case, it would be 300 mcg/hour / 1,000 mcg x 250 ml = 75 ml/hour. Therefore, the nurse should program the infusion pump to deliver 75 ml/hour. Choice A (50 ml/hour), Choice B (25 ml/hour), and Choice D (100 ml/hour) are incorrect as they do not correspond to the calculated rate of 75 ml/hour.

While caring for a toddler receiving oxygen (02) via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

  • A. Ask the mother what she usually uses on the child's lips and nose.
  • B. Apply a petroleum jelly (Vaseline) to the child's nose and lips.
  • C. Use a topical lidocaine (Zylocaine viscous) analgesic for cracked lips.
  • D. Use a water-soluble lubricant on affected oral and nasal mucosa.
Correct Answer: D

Rationale: A water-soluble lubricant is safe to use in conjunction with oxygen therapy, unlike petroleum jelly which is flammable.

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