HESI RN
HESI RN Exit Exam 2023
1. A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which clinical finding requires immediate intervention?
- A. Fever of 100.4°F
- B. Heart rate of 110 beats per minute
- C. Blood pressure of 140/90 mmHg
- D. Respiratory rate of 24 breaths per minute
Correct answer: A
Rationale: A fever of 100.4°F is a clinical finding that requires immediate intervention in a client with ESRD scheduled for hemodialysis. Fever may indicate an underlying infection, which can be severe in individuals with compromised renal function. Prompt assessment and treatment are essential to prevent worsening of the infection and potential complications. Heart rate, blood pressure, and respiratory rate are also important parameters to monitor in clients with ESRD, but in this scenario, the fever takes precedence due to its potential to indicate a critical condition that requires urgent attention.
2. A female client with major depressive disorder tells the nurse she feels worthless and can't see how her life will ever get better. What is the best response by the nurse?
- A. I can understand how you feel. Tell me more about what's been going on.
- B. You're going through a tough time. Let's discuss what makes you feel this way.
- C. You sound very hopeless right now. Are you thinking about harming yourself?
- D. It's difficult to see the light when you're feeling this way, but I'm here to help you.
Correct answer: C
Rationale: Choice C is the best response because it directly addresses the client's expressed hopelessness and assesses the risk for self-harm. When a client with major depressive disorder expresses feeling worthless and unable to see improvement, it is essential to assess suicidal ideation to ensure their safety. Choices A, B, and D provide empathy and support, which are important but addressing suicidal ideation is the priority in this situation.
3. A client with a head injury is receiving mechanical ventilation. Which finding indicates to the nurse that the client may be experiencing increased intracranial pressure (ICP)?
- A. Widening pulse pressure
- B. Sudden drop in heart rate
- C. A decrease in urine output
- D. Elevated blood pressure and widening pulse pressure
Correct answer: D
Rationale: In a client with increased intracranial pressure (ICP), the body's compensatory mechanisms lead to an elevation in blood pressure and a widening pulse pressure. This occurs due to the body's attempt to maintain cerebral perfusion. Therefore, elevated blood pressure and widening pulse pressure are classic signs of increased ICP and necessitate immediate attention. Choices A, B, and C are incorrect because a widening pulse pressure, sudden drop in heart rate, or decreased urine output are not specific indicators of increased ICP.
4. A client with hyperkalemia is receiving insulin and glucose. Which laboratory value should the nurse monitor closely?
- A. Monitor the client's blood glucose level.
- B. Monitor the client's sodium level.
- C. Monitor the client's calcium level.
- D. Monitor the client's potassium level.
Correct answer: D
Rationale: The correct answer is to monitor the client's potassium level. When administering insulin and glucose in hyperkalemia, the aim is to shift potassium from the bloodstream into the cells, lowering elevated levels. Therefore, monitoring potassium levels closely is essential to prevent hypokalemia or further complications. Monitoring blood glucose levels (Choice A) is important but not the priority in this scenario. Monitoring sodium (Choice B) and calcium levels (Choice C) is not directly related to the treatment of hyperkalemia with insulin and glucose.
5. A male client with schizophrenia is being discharged from the psychiatric unit after being stabilized with antipsychotic medications. What is the most important instruction to include in the discharge teaching?
- A. “You should see your psychiatrist every 6 months.”
- B. “It’s important to adhere to the medication regimen as prescribed.”
- C. “Try to avoid caffeine and alcohol completely.”
- D. “You should exercise daily to maintain a healthy lifestyle.”
Correct answer: B
Rationale: The most important instruction to include in the discharge teaching for a male client with schizophrenia who has been stabilized with antipsychotic medications is to adhere to the medication regimen as prescribed. Medication adherence is crucial in managing schizophrenia, preventing relapse, and maintaining stability. While seeing the psychiatrist regularly (Choice A) is important, adherence to medication is more critical for the client's immediate well-being. Avoiding caffeine and alcohol (Choice C) may be beneficial but is not as crucial as medication adherence. Daily exercise (Choice D) is important for overall health but is not the most critical instruction for managing schizophrenia.