HESI RN
HESI Exit Exam RN Capstone
1. A client with cirrhosis is prescribed spironolactone to manage ascites. Which serum laboratory value is most important for the nurse to monitor?
- A. Sodium
- B. Calcium
- C. Magnesium
- D. Potassium
Correct answer: D
Rationale: The correct answer is D: Potassium. Spironolactone is a potassium-sparing diuretic, which can lead to hyperkalemia. Monitoring potassium levels is crucial to prevent complications like cardiac arrhythmias. Choices A, B, and C are incorrect because sodium, calcium, and magnesium levels are not directly affected by spironolactone use for managing ascites in cirrhosis.
2. The nurse reviews the laboratory findings of a client with an open fracture of the tibia. The white blood cell (WBC) count and erythrocyte sedimentation rate (ESR) are elevated. Before reporting this information to the healthcare provider, what assessment should the nurse obtain?
- A. Appearance of wound
- B. Pain level
- C. Presence of fever
- D. Mobility status
Correct answer: A
Rationale: The correct answer is A: Appearance of wound. Elevated WBC and ESR levels suggest a possible infection in the client with an open fracture. Assessing the wound's appearance is crucial to evaluate for signs of infection, such as redness, warmth, swelling, or drainage. By assessing the wound first, the nurse can provide important information to the healthcare provider regarding the potential infection, which may require immediate intervention. Choices B, C, and D are important assessments in caring for a client with an open fracture; however, in this scenario, the priority is to assess the wound for signs of infection due to the elevated WBC and ESR levels.
3. The infant scheduled for reduction of intussusception passes a soft-formed brown stool the day before the scheduled procedure. Which intervention should the nurse implement?
- A. Instruct the parents that the infant needs to be NPO.
- B. Notify the healthcare provider of the passage of brown stool.
- C. Obtain a stool specimen for laboratory analysis.
- D. Ask the parents about recent changes in the infant's diet.
Correct answer: B
Rationale: Notifying the healthcare provider is crucial in this situation because the passage of a brown stool may indicate the resolution of intussusception. It is important to keep the healthcare provider informed about any changes in the infant's condition to ensure appropriate care and management. Instructing the parents that the infant needs to be NPO (nothing by mouth) is not necessary based on the passage of brown stool. Obtaining a stool specimen for laboratory analysis is not indicated in this scenario since the brown stool is likely a positive sign. Asking about recent changes in the infant's diet is not the priority at this moment as notifying the healthcare provider takes precedence.
4. In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The LPN/LVN bases the explanation on knowledge that for the normal newborn, the
- A. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week.
- B. anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week.
- C. anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month.
- D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.
Correct answer: D
Rationale: The anterior fontanel typically closes between 12 to 18 months, while the posterior fontanel usually closes by the end of the second month. It is important for parents to know these timeframes as it helps in monitoring the normal growth and development of their newborn. Delayed closure of fontanels may indicate potential health issues, and early closure may also warrant further evaluation by healthcare providers.
5. A 4-month-old girl is brought to the clinic by her mother because she has had a cold for 2 or 3 days and woke up this morning with a hacking cough and difficulty breathing. Which additional assessment finding should alert the nurse that the child is in acute respiratory distress?
- A. Bilateral bronchial breath sounds.
- B. Diaphragmatic breathing.
- C. A resting respiratory rate of 35 breaths per minute.
- D. Flaring of the nares.
Correct answer: D
Rationale: Flaring of the nares is a classic sign of acute respiratory distress in infants. It indicates increased work of breathing and is a visible cue that the child is struggling to breathe. This finding should alert healthcare providers to the severity of the respiratory distress and the need for prompt intervention to support the child's breathing. Choices A, B, and C are incorrect. Bilateral bronchial breath sounds are associated with conditions like pneumonia, but they do not specifically indicate acute respiratory distress. Diaphragmatic breathing is a normal breathing pattern and not a sign of distress. A resting respiratory rate of 35 breaths per minute is within the expected range for a 4-month-old infant and does not necessarily indicate acute respiratory distress.