HESI RN
HESI RN Exit Exam 2023
1. A healthcare provider is assessing a client with a history of hypertension who is currently taking a diuretic. Which assessment finding is most important to report to the healthcare provider?
- A. Potassium level of 3.2 mEq/L
- B. Blood pressure of 148/90 mmHg
- C. Pulse rate of 62 beats per minute
- D. Blood glucose level of 130 mg/dl
Correct answer: A
Rationale: A potassium level of 3.2 mEq/L is low and places the client at risk for cardiac arrhythmias, requiring immediate intervention. Hypokalemia can result from diuretic use and can lead to serious complications such as irregular heart rhythms. Monitoring and correcting potassium levels are crucial in preventing adverse cardiac events. The other options, though important, do not pose an immediate life-threatening risk compared to the low potassium level.
2. During the initial visit, which intervention is most important for the nurse to implement?
- A. Determine how the client is cared for when the caregiver is not present.
- B. Develop a client needs assessment and review it with the caregiver.
- C. Evaluate the caregiver's ability to care for the client's needs.
- D. Review with the caregiver the interventions provided each day.
Correct answer: A
Rationale: The most important intervention for the nurse to implement during the initial visit is to determine how the client is cared for when the caregiver is not present. This is crucial for ensuring continuous and adequate care, especially for a bed-bound client with multiple sclerosis who relies heavily on the caregiver. While developing a client needs assessment (choice B) and evaluating the caregiver's ability (choice C) are important, understanding the care plan in the caregiver's absence takes precedence. Reviewing daily interventions with the caregiver (choice D) is valuable but not as critical as knowing the care plan during the caregiver's absence.
3. A client with a history of severe rheumatoid arthritis is receiving a corticosteroid. Which assessment finding should the nurse report to the healthcare provider immediately?
- A. Blood glucose level of 180 mg/dL
- B. Weight gain of 2 pounds in 24 hours
- C. Blood pressure of 140/90 mmHg
- D. Increased joint pain
Correct answer: C
Rationale: Elevated blood pressure (140/90 mmHg) is a significant finding that the nurse should report immediately. Hypertension can be a severe side effect of corticosteroid therapy, especially in clients with preexisting conditions like rheumatoid arthritis. It requires prompt intervention to prevent complications such as cardiovascular events. The other options, while important to monitor, are not as critical as elevated blood pressure in this context. A blood glucose level of 180 mg/dL may indicate hyperglycemia, weight gain could be due to fluid retention, and increased joint pain is expected in a client with severe rheumatoid arthritis.
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. Following discharge teaching, a male client with a duodenal ulcer tells the nurse he will drink plenty of dairy products to help coat and protect his ulcer. What is the best follow-up action by the nurse?
- A. Remind the client that it is also important to switch to decaffeinated coffee and tea.
- B. Suggest that the client also plans to eat frequent small meals to reduce discomfort.
- C. Review with the client the need to avoid foods that are rich in milk and cream.
- D. Reinforce this teaching by asking the client to list a dairy food that he might select.
Correct answer: C
Rationale: The correct answer is C because diets rich in milk and cream stimulate gastric acid secretion, which can exacerbate a duodenal ulcer. Therefore, it is essential to avoid foods that are rich in milk and cream. Choice A is incorrect because switching to decaffeinated coffee and tea does not address the issue of avoiding milk and cream products. Choice B is incorrect because while eating frequent small meals can help with discomfort, it does not address the specific issue of avoiding milk and cream. Choice D is incorrect as it does not address the need to avoid milk and cream products.
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