HESI RN
HESI RN Exit Exam
1. A client with a history of atrial fibrillation is admitted with a new onset of confusion. Which intervention should the nurse implement first?
- A. Obtain a blood glucose level.
- B. Administer an anticoagulant as prescribed.
- C. Perform a neurological assessment.
- D. Administer aspirin as prescribed.
Correct answer: C
Rationale: Performing a neurological assessment is the priority in this situation as it helps in evaluating the cause of the new onset of confusion in a client with atrial fibrillation. This assessment will provide crucial information about the client's neurological status, which can guide further interventions. Obtaining a blood glucose level (Choice A) is important but should not be the first step when dealing with a new onset of confusion. Administering an anticoagulant (Choice B) or aspirin (Choice D) may be necessary depending on the underlying cause, but assessing the neurological status comes first to determine the appropriate course of action.
2. An adolescent's mother calls the clinic because the teen is having recurrent vomiting and has been combative in the last 2 days. The mother states that the teen takes vitamins, calcium, and magnesium supplements along with aspirin. Which nursing intervention has the highest priority?
- A. Advise the mother to withhold all medications by mouth.
- B. Instruct the mother to take the teen to the emergency room.
- C. Recommend that the teen withhold food and fluids for 2 hours.
- D. Suggest that the adolescent breathe slowly and deeply.
Correct answer: B
Rationale: In this scenario, the highest priority nursing intervention is to instruct the mother to take the teen to the emergency room. The symptoms of recurrent vomiting, combative behavior, and the medications (vitamins, calcium, magnesium supplements, and aspirin) taken by the teen suggest a possible overdose or serious adverse reaction. Therefore, immediate medical evaluation is crucial to assess and manage any potential toxicity or adverse effects. Advising to withhold all medications by mouth (Choice A) may delay necessary treatment. Recommending withholding food and fluids for 2 hours (Choice C) may not address the underlying cause of the symptoms. Suggesting slow and deep breathing (Choice D) is not appropriate in this urgent situation requiring immediate medical attention.
3. The nurse is caring for a client with a tracheostomy who has thick, tenacious secretions. Which assessment finding is most concerning?
- A. Crepitus around the tracheostomy site
- B. Dry and cracked tracheostomy site
- C. Yellowing of the skin around the tracheostomy site
- D. Mucous plugging of the tracheostomy tube
Correct answer: D
Rationale: Mucous plugging of the tracheostomy tube is the most concerning finding in a client with a tracheostomy and thick secretions. This can lead to airway obstruction, which requires immediate intervention to maintain a patent airway. Crepitus around the tracheostomy site may indicate subcutaneous emphysema but does not pose an immediate threat to the airway. A dry and cracked tracheostomy site may require interventions to promote healing but is not as urgent as mucous plugging. Yellowing of the skin around the tracheostomy site could indicate infection or impaired circulation, which should be addressed but does not pose the same immediate risk as airway obstruction.
4. A client with a history of chronic heart failure is admitted with shortness of breath. Which assessment finding is most concerning?
- A. Crackles in the lungs
- B. Shortness of breath
- C. Elevated liver enzymes
- D. Heart rate of 100 beats per minute
Correct answer: C
Rationale: Elevated liver enzymes are concerning in a client with chronic heart failure as they may indicate liver congestion or worsening heart failure, requiring immediate intervention. While crackles in the lungs and shortness of breath are common in heart failure, elevated liver enzymes specifically point towards possible liver involvement due to heart failure. A heart rate of 100 beats per minute can be expected in a client with heart failure due to compensatory mechanisms, but elevated liver enzymes signal a more severe condition.
5. After a sudden loss of consciousness, a female client is taken to the ED, and the initial assessment indicates that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that she was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is most important to include in this client's discharge plan?
- A. Describe the signs and symptoms of hypoglycemia.
- B. Encourage a low-carbohydrate and high-protein diet.
- C. Reinforce the need to continue outpatient treatment.
- D. Suggest wearing a medical alert bracelet at all times.
Correct answer: B
Rationale: Encouraging a low-carbohydrate and high-protein diet is crucial for a client recovering from anorexia nervosa to prevent hypoglycemic episodes. Choice A is not the most important intervention at this point since the client is already aware of hypoglycemia based on the recent event. Choice C is important but not the priority in this situation where dietary intervention is crucial. Choice D, suggesting a medical alert bracelet, is not as essential as ensuring proper nutrition to prevent further hypoglycemic episodes.
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