HESI RN
HESI RN Exit Exam
1. A client with acute pancreatitis is admitted with severe abdominal pain. Which assessment finding should be reported to the healthcare provider immediately?
- A. Decreased bowel sounds
- B. Increased heart rate
- C. Decreased urine output
- D. Elevated blood glucose level
Correct answer: C
Rationale: Decreased urine output is concerning in a client with acute pancreatitis as it may indicate hypovolemia or renal impairment. In acute pancreatitis, decreased urine output can signify inadequate perfusion to the kidneys, leading to renal failure. While the other options are important to monitor in a client with acute pancreatitis, decreased urine output requires immediate attention to prevent further complications.
2. During the digital removal of a fecal impaction, the nurse should stop the procedure and take corrective action if which client reaction is noted?
- A. Temperature increases from 98.8° to 99.0° F.
- B. Pulse rate decreases from 78 to 52 beats/min.
- C. Respiratory rate increases from 16 to 24 breaths/min.
- D. Blood pressure increases from 110/84 to 118/88 mmHg.
Correct answer: B
Rationale: During digital removal of a fecal impaction, a vagal response can occur due to stimulation of the anal sphincter. If the client experiences bradycardia (pulse rate decreases), the nurse should stop the procedure immediately and take corrective action to prevent any complications. Choices A, C, and D are incorrect because they do not indicate a vagal response, which is the expected adverse reaction during this procedure.
3. A client is prescribed metformin for type 2 diabetes. What should the nurse emphasize in the client's teaching?
- A. Take the medication with meals to reduce the risk of GI upset.
- B. Report any muscle pain to the healthcare provider promptly.
- C. Avoid alcohol consumption while taking this medication.
- D. Monitor blood sugar levels regularly to prevent hypoglycemia.
Correct answer: C
Rationale: The correct answer is to avoid alcohol consumption while taking metformin. Alcohol can increase the risk of lactic acidosis when combined with metformin. Choice A is incorrect because metformin is usually recommended to be taken with meals to reduce GI upset. Choice B is important but not the priority; muscle pain is more commonly associated with other diabetes medications. Choice D is incorrect because metformin typically does not cause hypoglycemia but rather helps control blood sugar levels in type 2 diabetes.
4. A new mother asks the LPN/LVN, 'How do I know that my daughter is getting enough breast milk?' Which explanation should the nurse provide?
- A. Weigh the baby daily, and if she is gaining weight, she is eating enough.
- B. Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day.
- C. Offer the baby extra bottle milk after her feeding, and see if she is still hungry.
- D. If you're concerned, you might consider bottle feeding so that you can monitor her intake.
Correct answer: B
Rationale: The correct answer is B. Adequate voiding is a sign that the baby is receiving enough milk. Pale straw-colored urine 6 to 10 times a day indicates proper hydration and nutrition. This is a reliable indicator of adequate breast milk intake for the infant. Choice A is incorrect because weight gain alone may not always indicate sufficient milk intake. Choice C is incorrect because supplementing with bottle milk can interfere with establishing breastfeeding. Choice D is incorrect as it suggests switching to bottle feeding, which is not necessary if the baby is latching and voiding well.
5. After a full-term vaginal delivery, a postpartum client's white blood cell count is 15,000/mm3. What action should the nurse take first?
- A. Check the differential, as the WBC count can be normal for this client.
- B. Assess the client's temperature, pulse, and respirations every 4 hours.
- C. Notify the healthcare provider, as this finding may indicate infection.
- D. Assess the client's perineal area for signs of a perineal hematoma.
Correct answer: A
Rationale: In postpartum clients, a white blood cell count of 15,000/mm3 can be within normal limits due to physiological changes that occur after childbirth. Checking the differential count would provide a more detailed analysis of the specific types of white blood cells present, helping to differentiate between normal postpartum changes and potential infection. This action allows the nurse to gather more information before escalating the situation to the healthcare provider or initiating other assessments. Assessing vital signs and the perineal area are important aspects of postpartum care but may not be the priority in this scenario where the white blood cell count can be influenced by normal physiological changes.