HESI RN
HESI 799 RN Exit Exam
1. The nurse is preparing to administer an enema to a client with severe constipation. Which position is most appropriate for the client?
- A. Supine with the head elevated 30 degrees
- B. Left lateral with the right leg flexed
- C. Sims’ position with the right leg flexed
- D. Prone position with the head turned to the side
Correct answer: C
Rationale: Sims’ position with the right leg flexed is the most appropriate position for administering an enema to a client with severe constipation. This position helps in promoting the flow of the enema solution into the rectum and facilitates the evacuation of stool. Supine position with the head elevated 30 degrees (Choice A) is not ideal for administering an enema as it does not facilitate the flow of the solution. Left lateral position with the right leg flexed (Choice B) is not the best choice for administering an enema. Prone position with the head turned to the side (Choice D) is also not suitable for administering an enema as it does not assist in the proper administration and retention of the solution.
2. After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse?
- A. Bruises on arms and legs
- B. Round and tight abdomen
- C. Pitting edema in lower legs
- D. Capillary refill of 8 seconds
Correct answer: D
Rationale: In this situation, the client's capillary refill of 8 seconds is the assessment finding that warrants immediate intervention by the nurse. A capillary refill greater than 3 to 5 seconds indicates poor perfusion, which could be a sign of inadequate circulation and oxygenation. Checking capillary refill is a quick and useful way to assess peripheral perfusion. Bruises on arms and legs may indicate a bleeding disorder but are not as urgent as addressing poor perfusion. A round and tight abdomen could suggest ascites, which is already known in this case. Pitting edema in lower legs is a common finding in malnutrition and ascites but does not require immediate intervention as poor capillary refill does.
3. A client with newly diagnosed hypertension is being taught about lifestyle modifications by a nurse. Which client statement indicates a need for further teaching?
- A. ‘I will reduce my salt intake to help manage my blood pressure.’
- B. ‘I will start exercising regularly to help control my blood pressure.’
- C. ‘I will avoid drinking alcohol to help manage my blood pressure.’
- D. ‘I will limit my caffeine intake to help control my blood pressure.’
Correct answer: D
Rationale: The correct answer is D. Limiting caffeine intake is a positive lifestyle modification for managing hypertension. The statement indicates that the client understands the importance of reducing caffeine intake. Choices A, B, and C all reflect appropriate lifestyle modifications for managing hypertension, indicating good understanding by the client.
4. Which nursing intervention has the highest priority for a multigravida who delivered an hour ago?
- A. Maintain cold packs to the perineum for 24 hours.
- B. Assess the client's pain level frequently.
- C. Observe for appropriate interaction with the infant.
- D. Assess fundal tone and lochia flow.
Correct answer: D
Rationale: Assessing fundal tone and lochia flow is crucial in the immediate postpartum period to detect postpartum hemorrhage, a life-threatening complication. Monitoring these parameters allows for early identification of excessive bleeding, enabling prompt intervention. While maintaining cold packs to the perineum, assessing pain levels, and observing for appropriate interaction with the infant are important aspects of postpartum care, assessing fundal tone and lochia flow takes precedence due to its direct relevance to identifying and managing a potential emergency situation.
5. The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation. Which assessment finding requires immediate intervention?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 28 breaths per minute
- C. Tidal volume of 300 ml
- D. Blood pressure of 110/70 mmHg
Correct answer: C
Rationale: The correct answer is C. A tidal volume of 300 ml is concerning in a client with ARDS on mechanical ventilation because it indicates hypoventilation, which can lead to inadequate gas exchange and worsening respiratory status. This finding requires immediate intervention to optimize ventilation and oxygenation. Options A, B, and D are not as critical in this scenario. An oxygen saturation of 90% may be acceptable depending on the client's baseline condition and the target range set by the healthcare provider. A respiratory rate of 28 breaths per minute is slightly elevated but may not be immediately alarming. A blood pressure of 110/70 mmHg is within normal limits and does not require urgent intervention.
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