HESI RN
HESI RN Exit Exam 2023
1. A client with a history of myocardial infarction is admitted with chest pain. Which diagnostic test should the nurse anticipate preparing the client for first?
- A. Electrocardiogram (ECG)
- B. Chest X-ray
- C. Arterial blood gases (ABGs)
- D. Echocardiogram
Correct answer: A
Rationale: The correct answer is A: Electrocardiogram (ECG). An electrocardiogram should be performed first to assess for cardiac ischemia in a client with a history of myocardial infarction and chest pain. This test provides immediate information about the heart's electrical activity. Choice B, Chest X-ray, is used to visualize the structures of the chest, including the heart and lungs, but it does not directly assess for cardiac ischemia. Choice C, Arterial blood gases (ABGs), measures the oxygen and carbon dioxide levels in the blood and assesses acid-base balance, which is not the primary concern in this scenario. Choice D, Echocardiogram, is an ultrasound of the heart that provides information about the heart's structure and function, but it is not the initial diagnostic test for assessing cardiac ischemia in this situation.
2. Which information about mammograms is most important to provide a post-menopausal female client?
- A. Breast self-examinations are not necessary if annual mammograms are obtained.
- B. Radiation exposure is minimized by shielding the abdomen with a lead-lined apron.
- C. Yearly mammograms should be done regardless of previous normal screenings.
- D. Women at high risk should have annual routine and ultrasound mammograms.
Correct answer: C
Rationale: The most important information to provide a post-menopausal female client regarding mammograms is that yearly mammograms should be done regardless of previous normal screenings. It is crucial for post-menopausal women to continue regular mammograms as they are at a higher risk for breast cancer. Option A is incorrect as breast self-examinations are still recommended in addition to mammograms. Option B is not the most important information compared to the importance of regular mammograms. Option D is not the most important advice for all post-menopausal females but specifically for those at high risk, indicating a more targeted approach.
3. The nurse is planning care for a client with a stage III pressure ulcer. Which intervention is most important for the nurse to include in the plan of care?
- A. Reposition the client every 2 hours
- B. Cleanse the ulcer with normal saline
- C. Apply a moisture-retentive dressing
- D. Measure the ulcer's depth and diameter
Correct answer: D
Rationale: The correct answer is to measure the ulcer's depth and diameter. This intervention is crucial as it helps monitor healing progress and evaluate the effectiveness of the care plan. Measuring the ulcer provides valuable information about the wound's improvement or deterioration. Repositioning the client every 2 hours (Choice A) is important for preventing further skin breakdown but may not be the priority in this case. Cleansing the ulcer with normal saline (Choice B) is essential for wound care but not the most crucial intervention at this stage. Applying a moisture-retentive dressing (Choice C) can promote healing, but assessing the ulcer's dimensions is more critical for monitoring progress.
4. An infant delivered vaginally by an HIV-positive mother is admitted to the newborn nursery. What intervention should the healthcare provider perform first?
- A. Bathe the infant with an antimicrobial soap.
- B. Measure the head and chest circumference.
- C. Obtain the infant's footprints.
- D. Administer vitamin K (AquaMEPHYTON).
Correct answer: A
Rationale: The initial intervention should be to bathe the infant with an antimicrobial soap to reduce the risk of HIV transmission from maternal fluids. This immediate action helps minimize potential exposure to the virus and promotes infection control practices in the care of infants born to HIV-positive mothers. Choice B, measuring head and chest circumference, is important for assessing growth and development but not the priority in this scenario. Choice C, obtaining footprints, is a routine procedure but not a priority over infection control measures. Choice D, administering vitamin K, is important for clotting factors but does not address the immediate risk of HIV transmission.
5. What is the inner lining of the non-pregnant uterus called?
- A. Decidua
- B. Myometrium
- C. Endometrium
- D. Sponge layer
Correct answer: C
Rationale: The correct answer is C, Endometrium. The endometrium is the inner lining of the non-pregnant uterus that undergoes cyclic changes in response to hormonal fluctuations during the menstrual cycle. Choice A, Decidua, is the specialized membrane formed during pregnancy. Choice B, Myometrium, refers to the middle layer of the uterine wall composed of smooth muscle. Choice D, Sponge layer, is not a term used to describe the inner lining of the uterus.