RN HESI Exit Exam

RN HESI Exit Exam Related

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A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, III, aVF, and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement?

  • A. Obtain the results for STAT serum cardiac biomarkers.
  • B. Assess for contraindications for thrombolytic therapy.
  • C. Measure ST-segment height and waveform changes.
  • D. Transfer for percutaneous coronary intervention (PCI).
Correct Answer: B

Rationale: Assessing for contraindications for thrombolytic therapy is crucial as it determines whether the client is a candidate for reperfusion therapy. In this scenario, the client is presenting with symptoms and ECG changes consistent with an acute myocardial infarction (MI). Thrombolytic therapy aims at restoring blood flow to the heart muscle, reducing the size of the infarct. However, it is essential to assess for contraindications such as recent surgery, active bleeding, or a history of stroke to avoid potential complications. Obtaining serum cardiac biomarkers or measuring ST-segment changes are important steps in the diagnosis of MI but are not as time-sensitive as assessing for contraindications to thrombolytic therapy. Transfer for percutaneous coronary intervention (PCI) is a definitive treatment for MI, but assessing for thrombolytic therapy eligibility takes precedence in this acute situation.

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The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which assessment finding requires immediate intervention?

  • A. Elevated blood pressure
  • B. Increased fatigue
  • C. Headache
  • D. Elevated hemoglobin
Correct Answer: A

Rationale: The correct answer is A: Elevated blood pressure. In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, elevated blood pressure requires immediate intervention. This finding is concerning as it may indicate worsening hypertension, which can lead to further complications. Increased fatigue (choice B) is common in CKD but may not require immediate intervention unless severe. Headache (choice C) can be a symptom to monitor but does not pose an immediate threat like elevated blood pressure. Elevated hemoglobin (choice D) is actually a desired outcome of erythropoietin therapy and does not require immediate intervention.

A client with a history of heart failure presents to the clinic with nausea, vomiting, yellow vision, and palpitations. Which finding is most important for the nurse to assess for this client?

  • A. Assess distal pulses and signs of peripheral edema
  • B. Determine the client's level of orientation and cognition
  • C. Obtain a list of medications taken for cardiac history
  • D. Ask the client about exposure to environmental heat
Correct Answer: C

Rationale: The correct answer is to obtain a list of medications taken for cardiac history. The client's presentation is indicative of digitalis toxicity, commonly associated with medications like digoxin (Lanoxin) used in heart failure treatment. Understanding the client's medication history, particularly the use of digoxin, is crucial in confirming and managing digitalis toxicity. Assessing distal pulses and signs of peripheral edema (Choice A) may be relevant in heart failure but are not the priority in this case. Determining the client's level of orientation and cognition (Choice B) and asking about exposure to environmental heat (Choice D) are not directly related to the client's current symptoms and are less pertinent in this scenario.

A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which clinical finding is most concerning?

  • A. Serum glucose of 500 mg/dl
  • B. Blood pressure of 140/90 mmHg
  • C. Serum osmolarity of 320 mOsm/kg
  • D. Serum pH of 7.30
Correct Answer: C

Rationale: A serum osmolarity of 320 mOsm/kg is the most concerning finding in a client with hyperglycemic hyperosmolar syndrome (HHS). This level of osmolarity indicates severe dehydration and hyperosmolarity, putting the client at risk of complications like organ failure. Immediate intervention is crucial to address the dehydration and restore fluid balance. The other options, while important in the overall assessment of a client with HHS, do not directly indicate the severity of dehydration and hyperosmolarity seen with a high serum osmolarity level.

A client presents at the clinic with blepharitis. What instructions should the nurse provide for home care?

  • A. Use bilateral eye patches while sleeping to prevent injury to the eyes.
  • B. Wear sunglasses when outdoors to prevent photophobia.
  • C. Apply cold compresses to reduce inflammation.
  • D. Apply warm moist compresses then gently scrub eyelids with diluted baby shampoo.
Correct Answer: D

Rationale: The correct answer is D. Blepharitis is managed with warm moist compresses to help loosen debris and oils on the eyelids, followed by gentle scrubbing with a mild solution like diluted baby shampoo. This helps in controlling the condition. Choice A is incorrect as using eye patches while sleeping is not a standard recommendation for blepharitis. Choice B is incorrect as wearing sunglasses does not directly treat blepharitis but may help with light sensitivity. Choice C is incorrect as cold compresses are not typically used for blepharitis, as warm compresses are more effective in managing the condition.

A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother. During the assessment, the mother asks the nurse why her child is at the 5th percentile for growth. What response is best for the nurse to provide?

  • A. Does your child seem mentally slower than his peers also?
  • B. His smaller size is probably due to the heart disease
  • C. Haven't you been feeding him according to recommended daily allowances for children?
  • D. You should not worry about the growth tables. They are only averages for children
Correct Answer: B

Rationale: Heart disease can affect growth, leading to smaller size in children.

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