HESI RN
HESI RN Exit Exam 2023
1. Following a gunshot wound to the abdomen, a young adult male had an emergency bowel resection and received multiple blood products. His current blood pressure is 78/52 mm Hg, and he is being mechanically ventilated. His oxygen saturation is 87%. Laboratory values indicate hemoglobin of 7 g/dL, platelets of 20,000/mm³, and white blood cells of 2,000/mm³. Which intervention should the nurse implement first?
- A. Transfuse packed red blood cells.
- B. Obtain blood and sputum cultures.
- C. Infuse 1000 ml of normal saline.
- D. Titrate oxygen to keep O2 saturation above 90%.
Correct answer: A
Rationale: The correct answer is to transfuse packed red blood cells first. The client's low hemoglobin level of 7 g/dL indicates severe anemia, which requires immediate transfusion to increase oxygen-carrying capacity. While obtaining blood and sputum cultures (Choice B) is important to identify potential infections, addressing the critical issue of anemia takes precedence. Infusing normal saline (Choice C) may help with volume status but does not address the primary concern of low hemoglobin. Titration of oxygen (Choice D) is crucial, but transfusion to improve oxygen-carrying capacity should be the priority in this scenario.
2. The adult client admitted to the post-anesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6°F (34.8°C), a pulse rate of 88 beats/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/64 mmHg. Which action should the nurse implement?
- A. Take the client's temperature using another method.
- B. Raise the head of the bed to 60 to 90 degrees.
- C. Ask the client to cough and deep breathe.
- D. Check the blood pressure every five minutes for one hour.
Correct answer: A
Rationale: Taking the client's temperature using another method is the most appropriate action in this situation. A tympanic temperature of 94.6°F (34.8°C) is abnormally low and may not reflect the true core body temperature accurately. By using an alternative method, such as oral or rectal temperature measurement, the nurse can obtain a more reliable temperature reading. Raising the head of the bed (Choice B) is not directly related to addressing the low temperature. Asking the client to cough and deep breathe (Choice C) may be beneficial for respiratory function but does not address the temperature concern. Checking the blood pressure every five minutes for one hour (Choice D) is not the priority when the initial focus should be on accurate temperature assessment.
3. A client is recovering from a hip replacement surgery. What is the priority nursing intervention to prevent complications?
- A. Encourage bed rest to prevent strain on the hip
- B. Assist the client with early ambulation
- C. Provide continuous passive motion therapy
- D. Administer pain medication before activity
Correct answer: B
Rationale: The correct answer is B: Assist the client with early ambulation. Early ambulation is a key intervention to prevent complications like deep vein thrombosis (DVT) and promote circulation after hip replacement surgery. It also helps with overall recovery and reduces the risk of complications related to immobility, such as muscle atrophy and pressure ulcers. Choice A is incorrect as bed rest should be avoided to prevent complications associated with immobility. Choice C, continuous passive motion therapy, is not the priority intervention immediately post-hip replacement surgery. Choice D, administering pain medication before activity, is important but not the priority intervention to prevent complications in this case.
4. What is considered the main objective of the translation stage of protein synthesis?
- A. To produce amino acids
- B. To produce nucleotides
- C. To produce fatty acids
- D. To produce nucleic acids
Correct answer: A
Rationale: The correct answer is A: To produce amino acids. During the translation stage of protein synthesis, the mRNA is decoded to assemble a specific sequence of amino acids. These amino acids then fold into a functional protein. Choices B, C, and D are incorrect because the translation stage specifically deals with the production of amino acids, not nucleotides, fatty acids, or nucleic acids.
5. A 60-year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void?
- A. Have him drink several glasses of water
- B. Crede the bladder from the bottom to the top
- C. Assist him to stand by the side of the bed to void
- D. Wait 2 hours and have him try to void again
Correct answer: C
Rationale: Assisting the client to stand by the side of the bed to void is the most appropriate action in this situation. Standing to void often helps relieve the bladder, especially after surgery. Option A, having him drink several glasses of water, may not be as effective as the client might already be adequately hydrated. Option B, Crede maneuver, is a technique for emptying the bladder by applying manual pressure and is not the first-line intervention for a client who cannot void post-surgery. Option D, waiting 2 hours before trying to void again, may delay necessary intervention if the client is experiencing urinary retention.