HESI RN
HESI RN Exit Exam 2023
1. During the infusion of a second unit of packed red blood cells, the client's temperature increases from 99 to 101.6 F. Which intervention should the nurse implement?
- A. Stop the transfusion and start a saline infusion.
- B. Administer antipyretics and continue the transfusion.
- C. Monitor the client’s vital signs every 15 minutes.
- D. Notify the healthcare provider and continue the transfusion.
Correct answer: A
Rationale: An increase in temperature during a transfusion may indicate a transfusion reaction, which can be serious. Stopping the transfusion and starting a saline infusion is the priority action to prevent further complications and address the potential adverse reaction. Administering antipyretics (choice B) may mask the symptoms of a transfusion reaction, delaying appropriate treatment. While monitoring vital signs (choice C) is important, stopping the transfusion takes precedence to prevent harm. Notifying the healthcare provider (choice D) is essential but should not delay the immediate intervention of stopping the transfusion and starting a saline infusion.
2. A female client with type 2 diabetes reports that she has been taking her medications as prescribed but her blood glucose levels remain elevated. Which action should the nurse take first?
- A. Check the client's current blood glucose level.
- B. Assess the client's diet and medication adherence.
- C. Review the client's medication list for potential interactions.
- D. Obtain a hemoglobin A1c level.
Correct answer: C
Rationale: The correct action the nurse should take first is to review the client's medication list for potential interactions. This step is crucial as it can help identify any medications that might be contributing to the elevated blood glucose levels. Checking the current blood glucose level (choice A) is important but not the first action to address the ongoing issue. Assessing the client's diet and medication adherence (choice B) is also important, but reviewing the medication list should be the initial step to rule out any drug-related causes. Obtaining a hemoglobin A1c level (choice D) is a valuable assessment but may not address the immediate need to identify potential medication interactions.
3. The nurse is assessing a client with right-sided heart failure. Which finding requires immediate intervention?
- A. Jugular venous distention
- B. Peripheral edema
- C. Crackles in the lungs
- D. Elevated liver enzymes
Correct answer: C
Rationale: In a client with right-sided heart failure, crackles in the lungs are the most concerning finding as they indicate pulmonary congestion, which requires immediate intervention. Crackles suggest fluid accumulation in the lungs, leading to impaired gas exchange and potential respiratory distress. Jugular venous distention (Choice A) and peripheral edema (Choice B) are common findings in right-sided heart failure but do not indicate acute deterioration requiring immediate intervention. Elevated liver enzymes (Choice D) may be seen in chronic heart failure but do not warrant immediate action compared to the urgent need to address pulmonary congestion indicated by crackles in the lungs.
4. A client with gestational diabetes, at 39 weeks of gestation, is in the second stage of labor. After delivering the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first?
- A. Prepare the client for an emergency cesarean birth
- B. Encourage the client to move to a hands-and-knees position
- C. Assist the client to sharply flex her thighs up against the abdomen
- D. Lower the head of the bed and apply suprapubic pressure
Correct answer: C
Rationale: In cases of shoulder dystocia, the priority intervention is to assist the client in sharply flexing her thighs up against the abdomen (McRoberts maneuver). This action helps to widen the pelvic outlet. Encouraging the client to move to a hands-and-knees position may also be beneficial in some cases but is not the first-line intervention. Preparing for an emergency cesarean birth and applying suprapubic pressure are not appropriate initial interventions for shoulder dystocia.
5. A client with a history of chronic heart failure is admitted with shortness of breath. Which laboratory value should be closely monitored?
- A. Serum sodium level
- B. Serum potassium level
- C. Serum creatinine level
- D. Hemoglobin level
Correct answer: B
Rationale: Corrected Rationale: In a client with chronic heart failure, serum potassium levels should be closely monitored to assess for hyperkalemia, which can worsen heart failure. Monitoring serum sodium levels is not the priority in this case. Serum creatinine level monitoring is more related to kidney function than heart failure. Hemoglobin levels are important but not the primary concern when assessing heart failure exacerbation.
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