HESI RN
RN HESI Exit Exam
1. The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which assessment finding is most concerning?
- A. Increased fatigue
- B. Elevated blood pressure
- C. Low urine output
- D. Elevated hemoglobin
Correct answer: B
Rationale: In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, an elevated blood pressure is the most concerning assessment finding. Elevated blood pressure can indicate worsening hypertension, which requires immediate intervention. Increased fatigue may be expected due to anemia associated with CKD and erythropoietin therapy. Low urine output may indicate impaired kidney function but is not as immediately concerning as elevated blood pressure. Elevated hemoglobin levels are the desired outcome of erythropoietin therapy, indicating an appropriate response to treatment.
2. The nurse is caring for a 17-year-old male who fell 20 feet 5 months ago while climbing the side of a cliff and has been in a sustained vegetative state since the accident. Which intervention should the nurse implement?
- A. Talk directly to the adolescent while providing care
- B. Maintain silence during care to avoid overstimulation
- C. Play soothing music in the background
- D. Limit visitors to immediate family only
Correct answer: A
Rationale: Talking directly to the adolescent is the most appropriate intervention in this scenario. It helps maintain a sense of connection and respect, even if the response is not evident. Maintaining silence may lead to isolation and hinder any potential communication attempts. Playing soothing music may not provide the personal interaction needed for connection. Limiting visitors to immediate family only may deprive the patient of diverse interactions that could be beneficial for their emotional well-being.
3. A client with a history of chronic heart failure is admitted with shortness of breath and crackles in the lungs. Which laboratory value should be closely monitored?
- A. Serum creatinine of 2.0 mg/dL
- B. Serum sodium of 135 mEq/L
- C. Serum potassium of 5.5 mEq/L
- D. Blood glucose of 150 mg/dL
Correct answer: C
Rationale: A serum potassium level of 5.5 mEq/L should be closely monitored in a client with chronic heart failure as it may indicate hyperkalemia, requiring intervention. Hyperkalemia can lead to life-threatening cardiac arrhythmias in patients with heart failure. Serum creatinine (Choice A) is important to monitor for kidney function but is not the priority in this case. Serum sodium (Choice B) and blood glucose (Choice D) levels are not typically the primary focus when assessing a client with heart failure presenting with respiratory symptoms and crackles in the lungs.
4. Following routine diagnostic tests, a client who is symptom-free is diagnosed with Paget's disease. Client teaching should be directed toward what important goal for this client?
- A. Maintain adequate cardiac output.
- B. Promote adequate tissue perfusion.
- C. Promote rest and sleep.
- D. Reduce the risk for injury.
Correct answer: D
Rationale: In Paget's disease, bone remodeling is affected, leading to increased risk for fractures. Therefore, the primary goal of client teaching should focus on reducing the risk for injury. Choices A and B are not directly related to the primary concern of Paget's disease, which is bone fractures. Choice C, promoting rest and sleep, is important for overall health but is not the priority when considering the specific risks associated with Paget's disease.
5. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which laboratory value is most concerning?
- A. Serum sodium of 135 mEq/L
- B. Serum potassium of 4.0 mEq/L
- C. Serum bicarbonate of 18 mEq/L
- D. Serum glucose of 300 mg/dL
Correct answer: C
Rationale: A serum bicarbonate level of 18 mEq/L is most concerning in a client with COPD as it indicates metabolic acidosis, requiring immediate intervention. In COPD, patients often retain carbon dioxide, leading to respiratory acidosis. A low serum bicarbonate level suggests that the body is compensating for this respiratory acidosis by increasing bicarbonate levels to maintain balance. Therefore, a low serum bicarbonate level in this scenario is alarming. Choices A, B, and D are within normal ranges and not directly related to the acid-base imbalance seen in COPD.
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