HESI RN
HESI RN Exit Exam 2023
1. An adult male who lives alone is brought to the Emergency Department by his daughter. He is unresponsive, with minimal respiratory effort, and his pupils are fixed and dilated. At the daughter's request, the client is intubated and mechanically ventilated. Which nursing intervention has the highest priority?
- A. Offer to notify the client's minister of his condition.
- B. Determine if the client has an executed living will.
- C. Provide the family with information about palliative care.
- D. Explore the possibility of organ donation with the family.
Correct answer: B
Rationale: The highest priority nursing intervention in this scenario is to determine if the client has an executed living will. A living will provides guidance on the client's preferences for medical care in situations where they cannot communicate. This information is crucial in guiding the care team on how to proceed with treatment. Options A, C, and D, though important in certain circumstances, are not the highest priority in this situation where immediate decisions regarding the client's care need to be made.
2. The charge nurse of the critical care unit informed at the beginning of the shift that a less than optimal number of registered nurses would be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse?
- A. A 34-year-old admitted today after an emergency appendectomy who has a peripheral intravenous catheter and a Foley catheter.
- B. A 48-year-old marathon runner with a central venous catheter experiencing nausea and vomiting due to electrolyte disturbance following a race.
- C. A 63-year-old chain smoker with chronic bronchitis receiving oxygen via nasal cannula and a saline-locked peripheral intravenous catheter.
- D. An 82-year-old client with Alzheimer's disease and a newly fractured femur with a Foley catheter and soft wrist restraints applied.
Correct answer: D
Rationale: The 82-year-old client with Alzheimer's disease and a newly fractured femur should receive the most care hours by a registered nurse because they are at the highest risk for injury and complications. The client's age, diagnosis of Alzheimer's disease, and the presence of a newly fractured femur along with the Foley catheter and wrist restraints indicate a need for close monitoring and care. Choice A is less critical as the client is stable post-appendectomy. Choice B, though experiencing symptoms, is not at the same level of risk as the client in Choice D. Choice C, while requiring oxygen support, does not have the same level of acuity and complexity as the client in Choice D.
3. The healthcare provider prescribes ceftazidime (Fortaz) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administer for each dose?
- A. 0.35 ml
- B. 0.40 ml
- C. 0.50 ml
- D. 0.45 ml
Correct answer: B
Rationale: To calculate the volume to be administered for 35 mg of ceftazidime, divide the prescribed dose by the concentration: 35 mg / 100 mg/ml = 0.35 ml. Rounding off, the nurse should administer 0.4 ml for each dose. Choice A is incorrect as it doesn't consider rounding off. Choice C is incorrect because it's not the correct calculation. Choice D is incorrect as it doesn't reflect the accurate volume needed.
4. The nurse notes that a client who has undergone a thoracotomy has an increase in a large amount of dark red blood in the chest tube collection chamber. What action should the nurse take?
- A. Document the findings for this procedure as expected
- B. Notify the healthcare provider immediately
- C. Check the tube for kinks or dependent loops
- D. Increase the suction to the chest drainage system
Correct answer: B
Rationale: An increase in a large amount of dark red blood in the chest tube collection chamber may indicate active bleeding. The nurse should notify the healthcare provider immediately to address the situation promptly and prevent further complications. Documenting the findings without taking immediate action could delay necessary interventions. Checking the tube for kinks or dependent loops is a good practice but not the priority when dealing with a potentially life-threatening situation like active bleeding. Increasing the suction without healthcare provider's orders can lead to complications and is not appropriate in this scenario.
5. A client with a spinal cord injury is admitted to the ICU. Which nursing intervention is most important to include in this client's plan of care?
- A. Monitor for signs of autonomic dysreflexia.
- B. Implement measures to prevent pressure ulcers.
- C. Perform passive range of motion exercises.
- D. Ensure that the client is turned every two hours.
Correct answer: A
Rationale: The correct answer is A: Monitor for signs of autonomic dysreflexia. Autonomic dysreflexia is a life-threatening condition that can occur in clients with spinal cord injuries, especially those with injuries above the T6 level. It is characterized by a sudden onset of excessively high blood pressure, pounding headache, profuse sweating, and flushing above the level of injury. Failure to recognize and treat autonomic dysreflexia promptly can lead to seizures, stroke, or even death. Therefore, monitoring for signs of autonomic dysreflexia is crucial in clients with spinal cord injuries. Choices B, C, and D are important interventions too, but in the context of a spinal cord injury, monitoring for autonomic dysreflexia takes priority due to its potentially life-threatening nature.
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