HESI RN
HESI RN Exit Exam 2023
1. A male client with impaired renal function who takes ibuprofen daily for chronic arthritis is showing signs of gastrointestinal (GI) bleeding. After administering IV fluids and a blood transfusion, his blood pressure is 100/70 mm Hg, and his renal output is 20 ml/hour. Which intervention should the nurse include in his care plan?
- A. Maintain the client NPO during the diuresis phase.
- B. Evaluate daily serial renal laboratory studies for progressive elevations.
- C. Observe the urine character for sedimentation and cloudy appearance.
- D. Monitor for the onset of polyuria greater than 150 ml/hour.
Correct answer: B
Rationale: In this scenario, the correct intervention for the nurse to include in the care plan is to evaluate daily serial renal laboratory studies for progressive elevations. This is crucial in monitoring renal function and detecting any worsening renal impairment. Option A is not directly related to managing renal function in this case. Option C focuses more on urinary characteristics rather than renal function monitoring. Option D addresses polyuria, which is an excessive urine output, but it does not specifically address the need for evaluating renal laboratory studies for progressive elevations.
2. Which of the following actions could be considered a breach of patient confidentiality?
- A. Discussing patient information with other healthcare providers in a private setting.
- B. Sharing patient information with family members without the patient's consent.
- C. Discussing patient information in public areas where others may overhear.
- D. Sharing patient information in a private, secure setting with other healthcare providers involved in the patient's care.
Correct answer: C
Rationale: Discussing patient information in public areas where others may overhear is considered a breach of patient confidentiality because it compromises the privacy and confidentiality of the patient's health information. Choices A and D are not breaches of confidentiality as discussing patient information with other healthcare providers in a private setting or in a private, secure setting with those involved in the patient's care is appropriate. Choice B is also incorrect as sharing patient information with family members without the patient's consent could potentially be a breach of privacy but is not the best answer in this context.
3. A client with urticaria due to environmental allergies is taking diphenhydramine (Benadryl). Which complaint should the nurse identify as a side effect of this OTC medication?
- A. Nausea and indigestion.
- B. Hypersalivation.
- C. Eyelid and facial twitching.
- D. Increased appetite.
Correct answer: A
Rationale: The correct answer is A: Nausea and indigestion. Diphenhydramine, an antihistamine, commonly causes gastrointestinal side effects such as nausea and indigestion. These symptoms are often reported by individuals taking this medication. Choices B, C, and D are incorrect because hypersalivation, eyelid and facial twitching, and increased appetite are not typically associated with diphenhydramine use.
4. To prevent unnecessary hypoxia during suctioning of a tracheostomy, what must the nurse do?
- A. Apply suction for no more than 10 seconds
- B. Maintain a sterile technique
- C. Lubricate 3 to 4 inches of the catheter tip
- D. Withdraw the catheter in a circular motion
Correct answer: A
Rationale: To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must apply suction for no more than 10 seconds. Prolonged suctioning can lead to hypoxia by removing too much oxygen from the patient. Maintaining a sterile technique (choice B) is important to prevent infection but does not directly relate to preventing hypoxia. Lubricating the catheter tip (choice C) helps with the insertion process but does not specifically address hypoxia prevention. Withdrawing the catheter in a circular motion (choice D) is not a standard practice during tracheostomy suctioning and does not contribute to preventing hypoxia.
5. After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral antacids without relief. Her vital signs are heart rate 122 beats/minute, respirations 16 breaths/minute, oxygen saturation 96%, and blood pressure 116/70. The nurse obtains a 12-lead electrocardiogram (ECG). Which assessment finding is most critical?
- A. Irregular pulse rhythm
- B. Bile-colored emesis
- C. ST elevation in three leads
- D. Complaint of radiating jaw pain
Correct answer: C
Rationale: ST elevation in three leads is a critical finding that suggests myocardial infarction, requiring immediate attention. This finding indicates ischemia or injury to the heart muscle. Choices A, B, and D are not as critical in this scenario. Irregular pulse rhythm may be concerning but does not indicate an immediate life-threatening condition like myocardial infarction. Bile-colored emesis and complaint of radiating jaw pain are relevant but not as indicative of a myocardial infarction as ST elevation in three leads.