HESI RN
RN HESI Exit Exam
1. A client with cirrhosis is admitted with jaundice and ascites. Which laboratory value requires immediate intervention?
- A. Serum albumin of 3.0 g/dL
- B. Serum bilirubin of 3.0 mg/dL
- C. Serum ammonia level of 80 mcg/dL
- D. Serum sodium level of 135 mEq/L
Correct answer: C
Rationale: A serum ammonia level of 80 mcg/dL is most concerning in a client with cirrhosis as it may indicate hepatic encephalopathy, requiring immediate intervention. High serum ammonia levels can lead to altered mental status, confusion, and even coma. Serum albumin (choice A) is often decreased in cirrhosis but does not require immediate intervention. Serum bilirubin (choice B) elevation is expected in cirrhosis and may not require immediate intervention unless very high. Serum sodium (choice D) within the given range is generally acceptable and does not require immediate intervention.
2. To reduce the risk of being named in a malpractice lawsuit, which action is most important for the nurse to take?
- A. Adhere consistently to standards of care.
- B. Thoroughly document all client interactions.
- C. Build a good rapport with clients.
- D. Work closely with the healthcare team.
Correct answer: A
Rationale: Adhering consistently to standards of care is crucial for nurses to reduce the risk of being named in a malpractice lawsuit. Following established protocols and guidelines ensures that the care provided is safe and effective. Thoroughly documenting all client interactions is also essential to support the care provided and to have a record of the interventions. Building a good rapport with clients is important for communication and trust but does not directly reduce the risk of malpractice. Working closely with the healthcare team is valuable for collaboration but might not directly impact the risk of malpractice unless it relates to following standards of care.
3. A client with a tracheostomy has thick, tenacious secretions. Which intervention should the nurse include in the plan of care?
- A. Encourage the client to drink plenty of fluids.
- B. Perform deep suctioning every 2 to 4 hours.
- 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. Encouraging the client to drink plenty of fluids can be beneficial for overall hydration but may not directly address thick secretions. Deep suctioning every 2 to 4 hours can be harmful and cause trauma to the airway lining. Administering a mucolytic agent should be done under the healthcare provider's order and may not be the initial intervention for thick secretions.
4. At 0600 while admitting a woman for a scheduled repeat cesarean section (C-Section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?
- A. Ensure preoperative lab results are available
- B. Start prescribed IV with lactated Ringer's
- C. Inform the anesthesia care provider
- D. Contact the client's obstetrician
Correct answer: C
Rationale: The correct action for the nurse to take first is to inform the anesthesia care provider. The patient's ingestion of coffee violates the NPO (nothing by mouth) guidelines before surgery, which increases the risk of aspiration during anesthesia. Informing the anesthesia care provider promptly allows for appropriate assessment and decision-making regarding the patient's anesthesia plan. Ensuring preoperative lab results, starting an IV, or contacting the obstetrician can be important steps but addressing the NPO violation and its implications on anesthesia safety take precedence.
5. A client with chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which assessment finding is most concerning?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 24 breaths per minute
- C. Use of accessory muscles
- D. Inspiratory crackles
Correct answer: C
Rationale: The correct answer is C: 'Use of accessory muscles.' In a client with COPD and pneumonia, the use of accessory muscles indicates increased work of breathing. This finding is concerning as it may signal respiratory failure, requiring immediate intervention. Oxygen saturation of 90% (choice A) is low but not as immediately concerning as the increased work of breathing. A respiratory rate of 24 breaths per minute (choice B) is slightly elevated but not as critical as the use of accessory muscles. Inspiratory crackles (choice D) may be present in pneumonia but are not as indicative of impending respiratory failure as the increased work of breathing shown by the use of accessory muscles.
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