HESI RN
HESI RN Exit Exam
1. The mother of a one-month-old boy born at home brings the infant to his first well-baby visit. She mentions that he was born two weeks after his due date and is a 'good, quiet baby' who almost never cries. To assess for hypothyroidism, what question is most important for the nurse to ask the mother?
- A. Has your son had any immunizations yet?
- B. Is your son sleepy and difficult to feed?
- C. Are you breastfeeding or bottle feeding your son?
- D. Were any relatives born with birth defects?
Correct answer: B
Rationale: The correct answer is B. Sleepiness and difficulty feeding are key signs of congenital hypothyroidism, which requires early diagnosis and treatment. Asking about immunizations (choice A) is important but not directly related to assessing hypothyroidism. The feeding method (choice C) is relevant for overall health but not specific to hypothyroidism. Inquiring about relatives with birth defects (choice D) is not the most crucial question to assess hypothyroidism in this scenario.
2. A client is admitted for cellulitis surrounding an insect bite on the lower right arm, and intravenous (IV) antibiotic therapy is prescribed. Which action should the nurse implement before performing venipuncture?
- A. Lower the right arm below the level of the heart.
- B. Elevate the right arm on a pillow.
- C. Apply a tourniquet above the insertion site.
- D. Apply a warm compress to the insertion site.
Correct answer: A
Rationale: Before performing venipuncture for IV therapy, the nurse should lower the right arm below the level of the heart. Lowering the arm helps dilate the veins, making it easier to locate and access a suitable vein for the procedure. Elevating the arm on a pillow, applying a tourniquet above the insertion site, or applying a warm compress to the insertion site are not appropriate actions before venipuncture as they can affect the venous blood flow and make the procedure more challenging.
3. A client with rheumatoid arthritis is scheduled to receive a dose of methotrexate. Which laboratory result is most important for the nurse to review before administering the medication?
- A. White blood cell count
- B. Liver function tests
- C. Kidney function tests
- D. Complete blood count
Correct answer: B
Rationale: The correct answer is B: Liver function tests. Before administering methotrexate, it is crucial to review liver function tests due to the medication's potential hepatotoxic effects. Methotrexate can cause liver damage, so monitoring liver function is essential to prevent any serious complications. While white blood cell count, kidney function tests, and complete blood count are important parameters to monitor in certain situations, they are not the most critical before administering methotrexate.
4. A client with a history of rheumatoid arthritis is prescribed methotrexate. Which laboratory value should the nurse monitor closely?
- A. Liver function tests
- B. Complete blood count
- C. Serum creatinine
- D. Prothrombin time
Correct answer: C
Rationale: Serum creatinine should be closely monitored in a client receiving methotrexate, as the medication can cause nephrotoxicity. Monitoring serum creatinine levels helps assess kidney function and detect potential nephrotoxic effects of methotrexate. Liver function tests (Choice A) are important to monitor for hepatotoxicity caused by methotrexate. While methotrexate can cause bone marrow suppression, leading to anemia, leukopenia, and thrombocytopenia, monitoring a complete blood count (Choice B) is essential but not the priority in this case. Prothrombin time (Choice D) is not typically affected by methotrexate therapy and is not the primary laboratory value to monitor in this situation.
5. Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3-minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide?
- A. Ask a more experienced nurse to perform that scrub since it is the first time of the day
- B. Validate the nurse is implementing the OR policy for surgical hand scrub
- C. Inform the nurse that hand scrubs should be 3 minutes between cases.
- D. Direct the nurse to continue the surgical hand scrub for a 5-minute duration.
Correct answer: D
Rationale: The correct answer is to direct the nurse to continue the surgical hand scrub for a 5-minute duration. Surgical hand scrubs should last for 5 to 10 minutes, ensuring thorough cleaning and disinfection. Choice A is incorrect because the nurse should be guided to complete the scrub properly rather than having someone else do it. Choice B is incorrect as it does not address the duration of the hand scrub. Choice C is incorrect as it suggests a 3-minute hand scrub is sufficient, which is inadequate for proper preparation before surgery.
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