HESI RN
HESI RN Exit Exam
1. 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.
2. During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement?
- A. Notify the pediatrician immediately.
- B. Teach the parents about congenital heart defects.
- C. Document the finding in the infant's record.
- D. Apply oxygen via nasal cannula at 3 L/min.
Correct answer: C
Rationale: The correct intervention when a nurse finds an irregular heart rate in a newborn is to document the finding in the infant's record. An irregular heart rate is a common occurrence in newborns and does not necessarily require immediate medical intervention. Notifying the pediatrician immediately is unnecessary unless there are other concerning symptoms. Teaching the parents about congenital heart defects is not the priority in this situation. Applying oxygen via nasal cannula at 3 L/min is not indicated for an irregular heart rate without further assessment or medical indication.
3. A client with hypertension receives a prescription for enalapril, an angiotensin-converting enzyme inhibitor. What instruction should the nurse include in the medication teaching plan?
- A. Increase intake of potassium-rich foods
- B. Report increased bruising or bleeding
- C. Stop medication if a cough develops
- D. Limit intake of leafy green vegetables
Correct answer: B
Rationale: The correct answer is B: 'Report increased bruising or bleeding.' Enalapril, an ACE inhibitor, can lead to thrombocytopenia, a condition characterized by a low platelet count, which increases the risk of bruising and bleeding. Instructing the client to report any signs of increased bruising or bleeding is crucial for monitoring and managing this potential side effect. Choices A, C, and D are incorrect: A - Increasing potassium-rich foods is not directly related to the side effects of enalapril. C - Developing a cough is a common side effect of ACE inhibitors, but it does not warrant stopping the medication unless advised by a healthcare provider. D - Limiting intake of leafy green vegetables is not necessary with enalapril unless specifically instructed by a healthcare provider for individual reasons.
4. 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.
5. The nurse determines that a client's pupils constrict as they change focus from a far object. What documentation should the nurse enter about this finding?
- A. Pupils reactive to accommodation.
- B. Nystagmus present with pupillary focus.
- C. Peripheral vision intact.
- D. Consensual pupillary constriction present.
Correct answer: A
Rationale: The correct answer is A: 'Pupils reactive to accommodation.' When pupils constrict as the client changes focus from a far object to a near one, it indicates a normal response known as accommodation. This physiological process allows the eyes to adjust their focus, and it is a healthy finding. Choice B is incorrect because nystagmus is an involuntary eye movement, not related to the change in focus. Choice C is irrelevant to the scenario and does not describe the observed finding. Choice D refers to pupillary constriction in response to light, not accommodation to changes in focus.
Similar Questions
Access More Features
HESI RN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $69.99
HESI RN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $149.99