HESI RN
HESI RN Exit Exam
1. A client with a history of alcoholism is admitted with confusion, ataxia, and nystagmus. Which nursing intervention is a priority for this client?
- A. Monitor for signs of alcohol withdrawal.
- B. Administer thiamine as prescribed.
- C. Provide a quiet environment to reduce confusion.
- D. Initiate fall precautions.
Correct answer: B
Rationale: The correct answer is B: Administer thiamine as prescribed. Administering thiamine is crucial in clients with a history of alcoholism to prevent Wernicke's encephalopathy, which is characterized by confusion, ataxia, and nystagmus. Monitoring for signs of alcohol withdrawal (choice A) is important but not the priority. Providing a quiet environment (choice C) and initiating fall precautions (choice D) are important interventions, but administering thiamine takes precedence due to the risk of Wernicke's encephalopathy.
2. Which of these findings should the nurse report immediately after a client has a liver biopsy?
- A. Temperature of 99.5 degrees F (37.5 degrees C)
- B. Blood pressure of 108/70
- C. Pulse oximetry reading of 96%
- D. Severe abdominal pain
Correct answer: D
Rationale: The correct answer is D, severe abdominal pain. After a liver biopsy, severe abdominal pain is a critical finding that requires immediate reporting as it may indicate internal bleeding or damage to the liver. The other vital signs provided in choices A, B, and C are within normal limits and may not be directly related to complications post liver biopsy. Therefore, the priority is to address the severe abdominal pain promptly to prevent any further complications.
3. The nurse is caring for a 2-day old neonate who has not passed meconium and has a swollen abdomen. The healthcare provider reviews the flat plate X-ray of the abdomen and makes a tentative diagnosis of Hirschsprung's disease. Which pathophysiological process is consistent with this neonate's clinical picture?
- A. The congenital absence of parasympathetic ganglion cells to large intestine produces no peristalsis.
- B. Pyloric obstruction causes reflux and projectile hematemesis.
- C. Partial imperforated anal opening limits passage of stools.
- D. Peristalsis moving against the intestinal obstruction causing hyperactivity of the bowel.
Correct answer: A
Rationale: Hirschsprung's disease is caused by the absence of parasympathetic ganglion cells in the large intestine, leading to a lack of peristalsis and obstruction.
4. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?
- A. Respiratory apnea of 30 seconds
- B. Oxygen saturation rate of 88%
- C. Eight premature ventricular beats every minute
- D. Disconnected monitor signal for the last 6 minutes.
Correct answer: A
Rationale: The correct answer is A: Respiratory apnea of 30 seconds. Respiratory apnea indicates a cessation of breathing, which is a life-threatening emergency requiring immediate intervention. Priority should be given to assessing and managing airway, breathing, and circulation. Option B, oxygen saturation rate of 88%, can indicate hypoxemia, but addressing the lack of breathing takes precedence. Option C, eight premature ventricular beats every minute, and option D, a disconnected monitor signal, are important but do not pose an immediate threat to the client's life compared to respiratory apnea.
5. A client with congestive heart failure is prescribed digoxin. What symptom indicates digoxin toxicity?
- A. Monitor for muscle weakness and fatigue.
- B. Monitor for increased appetite and weight gain.
- C. Monitor for nausea and vomiting.
- D. Monitor for blurred vision or seeing yellow halos around objects.
Correct answer: D
Rationale: Corrected Rationale: Blurred vision or seeing yellow halos around objects are signs of digoxin toxicity, which can be life-threatening. These symptoms indicate an overdose of digoxin, requiring immediate medical attention. Muscle weakness and fatigue (Choice A) are not typically associated with digoxin toxicity. Increased appetite and weight gain (Choice B) are not indicative of digoxin toxicity either. Nausea and vomiting (Choice C) are common side effects of digoxin but are not specific signs of toxicity. Therefore, the correct answer is to monitor for blurred vision or seeing yellow halos around objects.