HESI RN
HESI RN Exit Exam 2024 Quizlet
1. An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The nurse notices the client has more energy and is giving her belongings away. Which intervention is best for the nurse to implement?
- A. Support the client by praising her progress.
- B. Ask the client if she has had any recent thoughts of harming herself.
- C. Reassure the client about the effectiveness of antidepressant drugs.
- D. Advise the client to keep her belongings for discharge.
Correct answer: B
Rationale: The correct intervention is to ask the client if she has had any recent thoughts of harming herself because increased energy and giving away belongings can be signs of suicidal ideation. Choice A is incorrect as it does not address the potential risk of self-harm. Choice C is incorrect because reassurance about medication effectiveness may not be appropriate in this situation. Choice D is incorrect as it dismisses the client's current behavior without addressing the underlying concern of potential self-harm.
2. When assessing a client who is at 12-weeks gestation, the LPN/LVN recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?
- A. At 16 weeks gestation.
- B. At 20 weeks gestation.
- C. At 24 weeks gestation.
- D. At 30 weeks gestation.
Correct answer: D
Rationale: The best time for the couple to attend childbirth preparation classes is around 30 weeks gestation, which is during the third trimester. Attending classes at this time allows the couple to learn essential information and skills as labor and delivery are approaching, maximizing the benefit of the classes. Option A is too early in the second trimester, and the couple might forget important details by the time labor approaches. Option B is also early in the second trimester, and attending later allows for better preparation. Option C is still in the second trimester, and waiting until the third trimester provides more practical knowledge closer to delivery.
3. The nurse is making assignments for a new graduate from a practical nursing program who is orienting to the unit. Because the unit is particularly busy this day, there will be little time to provide supervision of this new employee. Which client is the best for the nurse to assign to this newly graduated practical nurse?
- A. Whose discharge has been delayed because of a postoperative infection
- B. With poorly controlled type 2 diabetes who is on a sliding scale for insulin administration
- C. Newly admitted with a head injury who requires frequent assessments
- D. Receiving IV heparin that is regulated based on protocol
Correct answer: A
Rationale: The correct answer is A because a client with a stable infection requires less supervision and is suitable for the new nurse. Choice B involves insulin administration for a client with poorly controlled diabetes, which may require more experience and supervision. Choice C involves a newly admitted patient with a head injury who requires frequent assessments, indicating a need for close monitoring. Choice D involves a patient receiving IV heparin, which requires precise monitoring and adjustment based on protocol, making it a higher-risk assignment for a new nurse without close supervision.
4. A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor?
- A. Side effects of total parenteral nutrition (TPN) and Intralipids.
- B. Uremic irritation of mucous membranes and skin surfaces.
- C. Elevated creatinine and blood urea nitrogen (BUN).
- D. Hypovolemia and electrocardiographic (ECG) changes.
Correct answer: D
Rationale: During the diuretic phase of acute kidney injury (AKI), monitoring for hypovolemia and electrocardiographic (ECG) changes is crucial. Hypovolemia can occur due to the increased urine output in this phase, potentially leading to dehydration and electrolyte imbalances. Electrolyte imbalances can result in ECG changes, such as arrhythmias, which can be life-threatening. Therefore, careful monitoring of fluid status and ECG findings helps in preventing complications. Choices A, B, and C are not the most crucial parameters to monitor during the diuretic phase of AKI. Side effects of total parenteral nutrition (TPN) and Intralipids, uremic irritation of mucous membranes and skin surfaces, and elevated creatinine and blood urea nitrogen (BUN) are important considerations in other phases of AKI or in other conditions, but they are not the primary focus during the diuretic phase when hypovolemia and ECG changes take precedence.
5. A client with stress incontinence is being taught about pelvic muscle exercises. Which statements should be included by the nurse? (Select all that apply.)
- A. Starting and stopping the urine stream involves using pelvic muscles.
- B. Tighten pelvic muscles for a slow count of 10 and then relax for a slow count of 10.
- C. Pelvic muscle exercises can be performed in various positions: lying down, sitting up, and standing.
- D. A & B
Correct answer: D
Rationale: The correct statements to include when teaching a client with stress incontinence about pelvic muscle exercises are that starting and stopping the urine stream involve using pelvic muscles and that tightening pelvic muscles for a slow count of 10 and then relaxing for a slow count of 10 can help strengthen them. It is essential to highlight that pelvic muscle exercises can be performed in various positions, including lying down, sitting up, and standing. This variety in positions helps engage the muscles effectively. Performing these exercises 15 times in each position can aid in strengthening the pelvic floor muscles. Consistent exercise over several weeks typically leads to improved control over urine leakage. Choice C is incorrect because pelvic muscle exercises can be performed in different positions and are not limited to sitting upright with feet on the floor.