HESI RN
HESI RN Exit Exam 2023
1. A client with a tracheostomy has thick, tenacious secretions. Which intervention should the nurse implement first?
- A. Perform deep suctioning every 2 to 4 hours.
- B. Encourage the client to drink plenty of fluids.
- C. Increase humidity in the client's room.
- D. Administer a mucolytic agent.
Correct answer: C
Rationale: Increasing humidity in the client's room can help liquefy thick secretions and facilitate easier airway clearance in a client with a tracheostomy. This intervention should be implemented first as it is non-invasive and can often effectively address the issue of thick secretions. Performing deep suctioning (Choice A) should not be the first intervention as it is more invasive and should be done based on assessment findings. Encouraging the client to drink plenty of fluids (Choice B) is beneficial but may not provide immediate relief for thick secretions. Administering a mucolytic agent (Choice D) requires a healthcare provider's prescription and should be based on assessment data and the client's condition.
2. While removing staples from a male client's postoperative wound site, the nurse observes that the client's eyes are closed and his face and hands are clenched. The client states, 'I just hate having staples removed.' After acknowledging the client's anxiety, what action should the nurse implement?
- A. Attempt to distract the client with general conversation
- B. Administer a pain medication
- C. Continue with the procedure while reassuring the client
- D. Stop the procedure and notify the healthcare provider
Correct answer: A
Rationale: In this situation, the nurse should attempt to distract the client with general conversation. Distracting the client can help reduce anxiety and make the procedure less stressful. Administering pain medication (choice B) is not appropriate as the client's discomfort is related to anxiety, not physical pain. Continuing with the procedure while reassuring the client (choice C) may not address the client's anxiety effectively. Stopping the procedure and notifying the healthcare provider (choice D) is not necessary at this point since the client's anxiety can be managed by attempting to distract him.
3. A 7-year-old boy is brought to the clinic because of facial edema. He reports that he has been voiding small amounts of dark, cloudy, tea-colored urine. The parents state that their son had a sore throat 2 weeks earlier, but it has resolved. After assessing the child's vital signs and weight, what intervention should the nurse implement next?
- A. Perform an otoscopic examination
- B. Measure the child's abdominal girth
- C. Collect a urine specimen for routine urinalysis
- D. Obtain a blood specimen for serum electrolytes
Correct answer: C
Rationale: Collecting a urine specimen for routine urinalysis is the next appropriate intervention. The symptoms described, including facial edema and tea-colored urine, are indicative of glomerulonephritis, a condition affecting the kidneys. A urine specimen can help assess renal function and the presence of blood and protein in the urine, which are common in glomerulonephritis. Performing an otoscopic examination (Choice A) is not relevant to the presenting symptoms. Measuring the child's abdominal girth (Choice B) is not necessary at this point as it does not directly address the urinary symptoms. Obtaining a blood specimen for serum electrolytes (Choice D) may provide information about electrolyte imbalances but is not the most appropriate initial step in this case.
4. 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.
5. The nurse is assessing a client with left-sided heart failure. Which clinical finding requires immediate intervention?
- A. Jugular venous distention
- B. Shortness of breath
- C. Crackles in the lungs
- D. Peripheral edema
Correct answer: C
Rationale: Corrected Rationale: In a client with left-sided heart failure, crackles in the lungs are the most concerning finding as they indicate pulmonary congestion, which requires immediate intervention to prevent worsening heart failure symptoms and respiratory distress. Jugular venous distention, shortness of breath, and peripheral edema are also common in heart failure but are not as critical as crackles in the lungs because they may indicate fluid overload or right-sided heart failure, which are important to address but not as urgently as managing pulmonary congestion.
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