HESI RN
HESI RN Exit Exam
1. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which assessment finding requires immediate intervention?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 24 breaths per minute
- C. Use of accessory muscles
- D. Inspiratory crackles
Correct answer: C
Rationale: The correct answer is C. The use of accessory muscles is most concerning in a client with COPD receiving supplemental oxygen as it indicates increased work of breathing, requiring immediate intervention. Oxygen saturation of 90% is acceptable in a client with COPD. A respiratory rate of 24 breaths per minute is slightly elevated but not as critical as the use of accessory muscles. Inspiratory crackles may be present in clients with COPD due to underlying lung changes but do not require immediate intervention unless associated with other concerning symptoms.
2. A client is admitted with a diagnosis of sepsis. Which assessment finding is most concerning to the nurse?
- A. Temperature of 101.5°F
- B. Heart rate of 110 beats per minute
- C. Respiratory rate of 24 breaths per minute
- D. Blood pressure of 90/60 mmHg
Correct answer: D
Rationale: A blood pressure of 90/60 mmHg in a client with sepsis is concerning for septic shock, a life-threatening condition that requires immediate intervention. Hypotension is a severe manifestation of sepsis that can lead to poor tissue perfusion and organ failure. While the other assessment findings such as an elevated temperature, increased heart rate, and respiratory rate are also common in sepsis, hypotension is particularly alarming as it indicates a critical state of shock and necessitates urgent medical attention.
3. A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever. Which instructions should the nurse give to this client?
- A. Come to the clinic to be seen by a healthcare provider
- B. Increase your fluid intake and rest at home
- C. Take over-the-counter antiemetics as needed
- D. Monitor your symptoms and call if they worsen
Correct answer: A
Rationale: The correct answer is to advise the client to come to the clinic to be seen by a healthcare provider. Persistent vomiting during pregnancy can lead to dehydration, which requires medical evaluation. Choice B is incorrect because solely increasing fluid intake and resting at home may not be sufficient to address the potential dehydration and underlying causes of vomiting. Choice C is not recommended without medical evaluation, as over-the-counter antiemetics should be used under healthcare provider guidance during pregnancy. Choice D is not the best option here because with persistent vomiting and risk of dehydration, immediate medical assessment is crucial to ensure the well-being of both the client and the fetus.
4. The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede Method. When performing a return demonstration, the client applies pressure to the umbilical areas of his abdomen. What instruction should the nurse provide?
- A. Stroke the inner thigh below the perineum to initiate urinary flow
- B. Contract, hold, and then relax the pubococcygeal muscle
- C. Pour warm water over the external sphincter at the distal glans
- D. Apply downward manual pressure at the suprapubic regions
Correct answer: D
Rationale: The client is applying pressure in the wrong region (umbilical area) and should be instructed to apply pressure at the suprapubic area. Applying downward manual pressure at the suprapubic region helps in emptying the bladder effectively by assisting in pushing the urine out through the urethra. Choices A, B, and C are incorrect because they do not address the specific issue of applying pressure to help empty the bladder using the Crede Method.
5. The nurse is caring for a client with a chest tube following a pneumothorax. Which assessment finding requires immediate intervention?
- A. Oxygen saturation of 94%
- B. Subcutaneous emphysema
- C. Crepitus around the insertion site
- D. Drainage of 50 ml per hour
Correct answer: B
Rationale: Subcutaneous emphysema is the correct answer as it is most concerning in a client with a chest tube following a pneumothorax. It may indicate a pneumothorax recurrence or air leak, requiring immediate intervention to prevent complications. Oxygen saturation of 94% is acceptable and does not require immediate intervention. Crepitus around the insertion site may be a normal finding after chest tube placement and does not necessarily indicate a complication. Drainage of 50 ml per hour is within the expected range for a chest tube and does not require immediate intervention.
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