HESI RN
HESI RN Exit Exam
1. A client with a history of atrial fibrillation is receiving warfarin (Coumadin). Which laboratory value should the nurse monitor closely?
- A. International Normalized Ratio (INR)
- B. Prothrombin time (PT)
- C. Serum sodium level
- D. Hemoglobin level of 12 g/dl
Correct answer: A
Rationale: The correct answer is A: International Normalized Ratio (INR). The INR should be closely monitored in a client receiving warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps ensure that the client is within the therapeutic range to prevent both bleeding and clotting events. Choices B, C, and D are incorrect because while PT is used to monitor warfarin therapy, INR is a more precise indicator of therapeutic levels. Serum sodium level and hemoglobin level are not directly related to monitoring warfarin therapy.
2. The healthcare provider is assessing a client undergoing peritoneal dialysis. Which of the following findings should be reported immediately to the physician?
- A. Clear dialysate outflow.
- B. Clear dialysate inflow.
- C. Cloudy dialysate outflow.
- D. Increased blood pressure.
Correct answer: C
Rationale: Cloudy dialysate outflow should be reported immediately to the physician as it is a concerning sign of peritonitis, a severe infection of the peritoneum. Peritonitis is a serious complication of peritoneal dialysis that requires prompt medical intervention to prevent further complications. Clear dialysate outflow and inflow are normal findings in peritoneal dialysis and do not indicate an immediate need for intervention. Increased blood pressure, while important to monitor, is not directly related to peritoneal dialysis and would not be the priority over the potentially life-threatening complication of peritonitis.
3. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 32 breaths/min and a heart rate of 110 beats/min. What action should the nurse take first?
- A. Administer a bronchodilator
- B. Encourage deep breathing and coughing
- C. Assess the client's oxygen saturation level
- D. Obtain an arterial blood gas
Correct answer: C
Rationale: The correct action for the nurse to take first is to assess the client's oxygen saturation level. In a client with COPD and abnormal respiratory and heart rates, determining the oxygen saturation helps evaluate the adequacy of oxygen exchange and the severity of respiratory distress. Administering a bronchodilator (choice A) can be appropriate but assessing oxygen saturation takes priority. Encouraging deep breathing and coughing (choice B) may not address the immediate need for oxygenation assessment. Obtaining an arterial blood gas (choice D) is important but typically follows the initial assessment of oxygen saturation.
4. At 34-40 weeks of pregnancy, the breast changes include:
- A. Nipples become prominent and mobile.
- B. Colostrum can be expressed.
- C. Breasts become tender.
- D. Montgomery's tubercles are prominent.
Correct answer: D
Rationale: During the 34-40 weeks of pregnancy, Montgomery's tubercles become prominent. These are sebaceous glands on the areola, not the nipples. Choice A is incorrect as it describes the changes in nipples, not Montgomery's tubercles. Choice B is incorrect as colostrum production usually starts around the 16th week. Choice C is incorrect as breast tenderness is more common in early pregnancy due to hormonal changes.
5. A client has just undergone insertion of a chest tube that is attached to a closed chest drainage system. Which action should the nurse plan to take in the care of this client?
- A. Assessing the client’s chest for crepitus every 24 hours
- B. Taping the connections between the chest tube and the drainage system
- C. Adding 20 mL of sterile water to the suction control chamber every shift
- D. Recording the volume of secretions in the drainage collection chamber every 24 hours
Correct answer: B
Rationale: The correct action for the nurse to take in caring for a client with a chest tube connected to a closed chest drainage system is to tape the connections between the chest tube and the drainage system. This is done to prevent accidental disconnection, ensuring the system functions properly. Assessing the client’s chest for crepitus should be done more frequently than once every 24 hours to monitor for any air leaks. Adding sterile water to the suction control chamber is not necessary every shift; it should be done as needed to maintain the appropriate water level. Recording the volume of secretions in the drainage collection chamber should be done more frequently than every 24 hours, with hourly monitoring during the first 24 hours after insertion and every 8 hours thereafter to assess for changes or complications.