HESI RN
HESI RN Exit Exam
1. Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3-minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide?
- A. Ask a more experienced nurse to perform that scrub since it is the first time of the day
- B. Validate the nurse is implementing the OR policy for surgical hand scrub
- C. Inform the nurse that hand scrubs should be 3 minutes between cases.
- D. Direct the nurse to continue the surgical hand scrub for a 5-minute duration.
Correct answer: D
Rationale: The correct answer is to direct the nurse to continue the surgical hand scrub for a 5-minute duration. Surgical hand scrubs should last for 5 to 10 minutes, ensuring thorough cleaning and disinfection. Choice A is incorrect because the nurse should be guided to complete the scrub properly rather than having someone else do it. Choice B is incorrect as it does not address the duration of the hand scrub. Choice C is incorrect as it suggests a 3-minute hand scrub is sufficient, which is inadequate for proper preparation before surgery.
2. An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7-pound infant 12 hours ago is reporting a severe headache. The client’s blood pressure is 110/70 mmHg, respiratory rate is 18 breaths/min, heart rate is 74 beats/min, and temperature is 98.6°F (37°C). What action should the charge nurse implement first?
- A. Notify the healthcare provider of the assessment findings.
- B. Administer analgesics as prescribed.
- C. Increase the client’s fluid intake.
- D. Monitor the client’s vital signs every hour.
Correct answer: A
Rationale: A severe headache post-delivery could indicate a serious condition such as preeclampsia or a spinal headache, which requires immediate medical attention. Notifying the healthcare provider of the assessment findings allows for prompt evaluation and appropriate management of the client's condition.
3. What causes the changes in appearance seen in boys at the time of puberty?
- A. Prolactin
- B. Adrenaline
- C. Estrogen
- D. Testosterone
Correct answer: D
Rationale: During puberty, boys experience physical changes such as growth of facial and body hair, deepening of the voice, and muscle development. These changes are primarily driven by the hormone testosterone. Testosterone is responsible for the development of male secondary sexual characteristics. Therefore, the correct answer is testosterone. Choices A, B, and C are incorrect because prolactin, adrenaline, and estrogen do not play a significant role in the development of male secondary sexual characteristics during puberty.
4. A female client reports that she drank a liter of a solution to cleanse her intestines but vomited immediately after. How many ml of fluid intake should the nurse document?
- A. 1000 ml
- B. 800 ml
- C. 760 ml
- D. 500 ml
Correct answer: C
Rationale: The correct answer is 760 ml. One liter equals 1000 ml. As the client vomited immediately after drinking, she would have expelled approximately 240 ml (1 cup). Subtracting this from the initial intake of 1000 ml gives us 760 ml as the remaining fluid intake that should be documented. Choices A, B, and D are incorrect because they do not reflect the correct calculation of subtracting the amount vomited from the initial intake.
5. While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse’s best response?
- A. As you urinate more, you will need less medication to control fluid.
- B. You will have to take this medication for about a year.
- C. The medication must be continued so the fluid problem is controlled.
- D. Please talk to your health care provider about medications and treatments.
Correct answer: C
Rationale: Diuretics must be continued as long as the fluid problem persists to prevent heart failure symptoms.