HESI RN
HESI RN Exit Exam 2023
1. When a male Korean-American client looks away when asked by the nurse to describe his problem, what is the best initial nursing action?
- A. Ask for assistance from social services to find a Korean interpreter.
- B. Establish indirect eye contact with the client.
- C. Allow several minutes for the client to respond.
- D. Repeat the question using simpler language.
Correct answer: C
Rationale: In this scenario, the best initial nursing action is to allow several minutes for the client to respond. This approach respects the cultural norms of the client, as in some cultures, direct eye contact may be perceived as disrespectful or intrusive. By giving the client time to gather his thoughts and respond at his own pace, the nurse promotes effective communication and demonstrates cultural sensitivity. Asking for assistance from social services to find a Korean interpreter (Choice A) may be necessary for further communication but is not the best initial action. Establishing indirect eye contact (Choice B) may still make the client uncomfortable. Repeating the question using simpler language (Choice D) may not address the underlying cultural aspect affecting the client's response.
2. Amniocentesis, a prenatal diagnostic test used to determine fetal sex, genetic anomalies, and biochemical abnormalities, is based on:
- A. The karyotyping of the amniotic fluid
- B. Chorionic villus sampling
- C. Umbilical cord blood sampling
- D. Ultrasound
Correct answer: A
Rationale: The correct answer is A. Amniocentesis involves the analysis of the fetal cells present in the amniotic fluid, which is extracted from the amniotic sac surrounding the developing fetus. This fluid contains cells shed by the fetus, which can be cultured and analyzed to obtain a karyotype, providing information about the fetal sex, genetic anomalies, and biochemical abnormalities. Choices B, C, and D are incorrect because chorionic villus sampling involves obtaining a sample of the chorionic villi from the placenta, not the amniotic fluid; umbilical cord blood sampling is typically used for other purposes like assessing the baby's blood for infections or genetic disorders; and ultrasound is a diagnostic imaging technique that does not involve the analysis of fetal cells for genetic information.
3. A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse’s station in a literally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?
- A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril).
- B. Offer the client a prescribed physical therapy hot pack for muscle spasms.
- C. Direct the client to occupational therapy to distract him from somatic complaints.
- D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.
Correct answer: D
Rationale: The correct action for the nurse to take in this situation is to administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. The client's symptoms of body contortion and feeling like a monster are indicative of acute dystonia, which can be a side effect of antipsychotic medications like risperidone. Benztropine can help alleviate these acute dystonic reactions. Choice A is incorrect because changing the antipsychotic medication at this point is not indicated. Choice B is not appropriate as the client's symptoms are likely due to acute dystonia rather than muscle spasms. Choice C is also not the best course of action as the client needs immediate intervention for the acute dystonic reaction.
4. The nurse must delegate some aspects of a homebound client's care to a home health aide. Which intervention should the nurse delegate to the home health aide?
- A. evaluating a pressure sore
- B. applying a prosthetic device
- C. performing a sterile dressing change
- D. assessing the client's need for an elevated toilet seat
Correct answer: B
Rationale: The correct answer is B: applying a prosthetic device. Home health aides are trained and authorized to assist with the application and management of prosthetic devices for clients. Evaluating a pressure sore (choice A) requires clinical assessment and judgment typically performed by a licensed healthcare provider such as a nurse. Performing a sterile dressing change (choice C) involves aseptic technique and wound care skills that are usually performed by licensed healthcare professionals. Assessing the client's need for an elevated toilet seat (choice D) involves a level of assessment and decision-making that is beyond the scope of practice for a home health aide.
5. A client is being cared for by a nurse due to severe back pain, and codeine sulfate has been prescribed. Which of the following should the nurse include in the plan of care while the client is taking this medication?
- A. Restrict fluid intake.
- B. Monitor bowel activity.
- C. Monitor for hypertension.
- D. Monitor peripheral pulses.
Correct answer: B
Rationale: When a client is prescribed codeine sulfate, it is essential to monitor bowel activity because this medication can lead to constipation. Therefore, monitoring bowel function is crucial to prevent or manage any potential gastrointestinal issues that may arise.