HESI RN
HESI RN Exit Exam 2023
1. The healthcare provider is assessing a client with left-sided heart failure. Which laboratory value should be monitored closely?
- A. Serum sodium of 135 mEq/L
- B. Serum potassium of 4.5 mEq/L
- C. Serum creatinine of 1.8 mg/dl
- D. Serum glucose of 200 mg/dl
Correct answer: C
Rationale: In a client with left-sided heart failure, monitoring serum creatinine is crucial to evaluate kidney function and fluid balance. Elevated creatinine levels can indicate impaired kidney function, which is common in heart failure due to decreased cardiac output and renal perfusion. Serum sodium levels (choice A) are important but are more closely associated with fluid balance and heart failure exacerbation. Serum potassium (choice B) is also important to monitor, but it is more closely linked to cardiac arrhythmias rather than kidney function. Serum glucose levels (choice D) are significant but are not the priority for monitoring in left-sided heart failure.
2. 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.
3. A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which clinical finding requires immediate intervention?
- A. Fever of 100.4°F
- B. Heart rate of 110 beats per minute
- C. Blood pressure of 140/90 mmHg
- D. Respiratory rate of 24 breaths per minute
Correct answer: A
Rationale: A fever of 100.4°F is a clinical finding that requires immediate intervention in a client with ESRD scheduled for hemodialysis. Fever may indicate an underlying infection, which can be severe in individuals with compromised renal function. Prompt assessment and treatment are essential to prevent worsening of the infection and potential complications. Heart rate, blood pressure, and respiratory rate are also important parameters to monitor in clients with ESRD, but in this scenario, the fever takes precedence due to its potential to indicate a critical condition that requires urgent attention.
4. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which assessment finding requires immediate intervention?
- A. Use of accessory muscles
- B. Oxygen saturation of 90%
- C. Respiratory rate of 24 breaths per minute
- D. Blood pressure of 110/70 mmHg
Correct answer: A
Rationale: The correct answer is A: Use of accessory muscles. This finding indicates increased work of breathing in a client with COPD and may signal respiratory failure, requiring immediate intervention. In COPD, the use of accessory muscles suggests that the client is in distress and struggling to breathe effectively. Oxygen saturation of 90% is within an acceptable range for a client with COPD receiving supplemental oxygen and does not require immediate intervention. A respiratory rate of 24 breaths per minute is slightly elevated but not a critical finding. A blood pressure of 110/70 mmHg is within the normal range for an adult and does not indicate a need for immediate intervention in this scenario.
5. A client with chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which laboratory value is most concerning?
- A. Serum potassium of 6.5 mEq/L
- B. Serum bicarbonate of 18 mEq/L
- C. Serum glucose of 350 mg/dl
- D. Serum sodium of 135 mEq/L
Correct answer: A
Rationale: A serum potassium level of 6.5 mEq/L is concerning in a client with COPD exacerbation as it may lead to life-threatening arrhythmias, requiring immediate intervention. Hyperkalemia can cause cardiac arrhythmias, which pose a significant risk to the patient's life. Options B, C, and D are not typically associated with immediate life-threatening risks in the context of a COPD exacerbation.
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