HESI RN
HESI RN Exit Exam
1. A client with chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which assessment finding requires immediate intervention?
- 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. The use of accessory muscles indicates increased work of breathing and can signal respiratory failure in a client with COPD. This finding requires immediate intervention to prevent further respiratory compromise. Oxygen saturation of 90% indicates some oxygenation impairment but may not necessitate immediate intervention. A respiratory rate of 24 breaths per minute is slightly elevated but does not indicate immediate respiratory distress. Inspiratory crackles may be present in pneumonia but do not require immediate intervention compared to the increased work of breathing indicated by the use of accessory muscles.
2. A male client with type 1 diabetes mellitus asks the nurse about taking an oral antidiabetic agent. Nurse Jack explains that these medications are only effective if the client:
- A. Prefers to take insulin orally.
- B. Has type 2 diabetes.
- C. Has type 1 diabetes.
- D. Is pregnant and has type 2 diabetes.
Correct answer: B
Rationale: Oral antidiabetic agents are specifically designed for type 2 diabetes mellitus. Type 1 diabetes requires insulin therapy as the primary treatment due to the absence of endogenous insulin production. Therefore, these medications are not effective for individuals with type 1 diabetes like the male client in this scenario. Choice A is incorrect as oral antidiabetic agents are not about preference but rather about treatment efficacy. Choice D is incorrect as being pregnant does not impact the effectiveness of oral antidiabetic agents; they are primarily indicated for type 2 diabetes.
3. The home health nurse provides teaching about insulin self-injection to a client who was recently diagnosed with diabetes mellitus. When the client begins to perform a return demonstration of an insulin injection into the abdomen, which instruction should the nurse provide?
- A. Select a different injection site
- B. Continue with the insulin injection
- C. Keep the skin flat rather than bunched
- D. Lie down flat for better skin exposure
Correct answer: B
Rationale: Choosing to continue with the insulin injection is the correct instruction in this scenario because it allows the client to demonstrate proper technique and reinforces their learning. Selecting a different injection site (choice A) is not necessary if the client is injecting into the abdomen as it is a suitable site. Keeping the skin flat rather than bunched (choice C) is a good practice but is not the priority in this situation where the client is demonstrating the injection technique. Lying down flat for better skin exposure (choice D) is not required and may not be practical for the client during routine self-injections.
4. A client asks the nurse for information about reducing risk factors for BPH. Which information should the nurse provide?
- A. Increase physical activity
- B. Decrease alcohol consumption
- C. Reduce intake of dairy products
- D. Avoid caffeine and spicy foods
Correct answer: A
Rationale: The correct answer is A: Increase physical activity. Physical activity can help reduce the risk of benign prostatic hyperplasia (BPH) by improving overall circulation and reducing inflammation. While decreasing alcohol consumption and avoiding caffeine and spicy foods may help with symptom management, increasing physical activity is more strongly linked to the prevention of BPH.
5. Which of the following Leopold maneuvers assesses the fetal lie?
- A. Fundal grip
- B. Umbilical grip
- C. Pawlick grip
- D. Pelvic grip
Correct answer: A
Rationale: The correct answer is A: Fundal grip. Fundal grip is a specific Leopold maneuver used to assess the fetal lie by palpating the upper abdomen to determine the position of the baby's back and presenting part. This maneuver helps healthcare providers understand the orientation of the fetus within the uterus. Choice B, Umbilical grip, is not a recognized Leopold maneuver and does not assess fetal lie. Choice C, Pawlick grip, and choice D, Pelvic grip, are also not part of the standard Leopold maneuvers used to determine fetal lie.