HESI RN
HESI RN Exit Exam 2023
1. A client with gestational diabetes, at 39 weeks of gestation, is in the second stage of labor. After delivering the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first?
- A. Prepare the client for an emergency cesarean birth
- B. Encourage the client to move to a hands-and-knees position
- C. Assist the client to sharply flex her thighs up against the abdomen
- D. Lower the head of the bed and apply suprapubic pressure
Correct answer: C
Rationale: In cases of shoulder dystocia, the priority intervention is to assist the client in sharply flexing her thighs up against the abdomen (McRoberts maneuver). This action helps to widen the pelvic outlet. Encouraging the client to move to a hands-and-knees position may also be beneficial in some cases but is not the first-line intervention. Preparing for an emergency cesarean birth and applying suprapubic pressure are not appropriate initial interventions for shoulder dystocia.
2. The nurse is teaching a nursing student about the minimal effective concentration (MEC) of antibiotics. Which statement by the nursing student indicates understanding of this concept?
- A. A serum drug level greater than the MEC ensures that the drug is bacteriostatic.
- B. A serum drug level greater than the MEC broadens the spectrum of the drug.
- C. A serum drug level greater than the MEC helps eradicate bacterial infections.
- D. A serum drug level greater than the MEC increases the therapeutic index.
Correct answer: C
Rationale: The MEC is the minimum amount of drug needed to halt the growth of a microorganism. A level greater than the MEC helps eradicate infections. Drugs at or above the MEC are usually bactericidal, not bacteriostatic. Therefore, choice A is incorrect. Broadening the spectrum of a drug refers to its range of activity against different microorganisms, which is not directly related to MEC. Thus, choice B is incorrect. Increasing the therapeutic index involves maximizing the effectiveness of a drug while minimizing its toxicity, which is not specifically related to MEC. Therefore, choice D is also incorrect.
3. The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow-up rather than delegate care to the nursing assistant?
- A. Has had a change in respiratory rate with an increase of 2 breaths
- B. Has had a change in heart rate with an increase of 10 beats
- C. Was minimally responsive to voice and touch
- D. Has had a blood pressure change with a drop of 8 mmHg systolic
Correct answer: C
Rationale: A change in responsiveness, as indicated by being minimally responsive to voice and touch, suggests a potential acute issue that requires immediate nursing assessment and intervention rather than delegation. Changes in vital signs (choices A, B, D) can be important but do not always indicate an immediate need for nursing intervention compared to a change in responsiveness.
4. A client receiving continuous ambulatory peritoneal dialysis (CAPD) has lost weight and exhibits increasing edema. What should the nurse prioritize?
- A. Evaluate the patency of the arteriovenous (AV) graft.
- B. Instruct the client to continue a fluid-restricted diet.
- C. Recommend support stockings for venous return.
- D. Monitor the client's serum albumin levels.
Correct answer: A
Rationale: In a client receiving continuous ambulatory peritoneal dialysis (CAPD) who has lost weight and exhibits increasing edema, the nurse should prioritize evaluating the patency of the arteriovenous (AV) graft. This assessment is crucial to determine if hemodialysis can be resumed, addressing the client's presenting issues effectively. Instructing the client to continue a fluid-restricted diet (choice B) may not address the underlying issue related to the CAPD. Recommending support stockings for venous return (choice C) is not directly relevant to the situation described. Monitoring the client's serum albumin levels (choice D) may be important but does not directly address the immediate concern of weight loss and increasing edema in a CAPD client.
5. During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first?
- A. Use a laryngoscope to check for a foreign body lodged in the airway.
- B. Reposition the head to ensure that the airway is properly opened.
- C. Turn the client to the side and administer three back blows.
- D. Perform a finger sweep of the mouth to clear any obstructions.
Correct answer: B
Rationale: The most common reason for inadequate lung aeration during CPR is the incorrect positioning of the head, leading to airway obstruction. Therefore, the initial action should be to reposition the head to open the airway properly and attempt to ventilate again. Using a laryngoscope to check for foreign bodies in the airway (Choice A) is not the first step and could delay crucial interventions. Turning the client to the side and administering back blows (Choice C) is not indicated in this scenario as the focus is on ventilating the lungs. Performing a finger sweep of the mouth (Choice D) is not recommended as it may push obstructions further into the airway during CPR.