HESI RN
HESI RN Exit Exam 2023
1. When planning care for a 10-year-old child with pneumonia receiving oxygen at 5l/min per nasal cannula, what principle of oxygen administration should the nurse consider?
- A. Avoid administration of oxygen at high levels for extended periods.
- B. Increase oxygen flow rate if the child is still tachypneic.
- C. Reduce oxygen levels gradually after symptoms improve.
- D. Humidify the oxygen to prevent drying of mucous membranes.
Correct answer: A
Rationale: The correct principle of oxygen administration to consider is to avoid administering oxygen at high levels for extended periods. High levels of oxygen for prolonged periods can lead to oxygen toxicity, especially in pediatric patients. Increasing the oxygen flow rate based on tachypnea may not be necessary and can potentially lead to oxygen toxicity. Gradually reducing oxygen levels after symptoms improve may compromise the child's oxygenation. While humidifying oxygen is important to prevent drying of mucous membranes, the primary concern in this case is to avoid high oxygen levels for an extended duration to prevent oxygen toxicity.
2. In assessing a client with type 1 diabetes mellitus, the nurse notes that the client's respirations have changed from 16 breaths/min with a normal depth to 32 breaths/min and deep, and the client becomes lethargic. Which assessment data should the nurse obtain next?
- A. Pulse oximetry
- B. Blood glucose
- C. Arterial blood gases
- D. Serum electrolytes
Correct answer: B
Rationale: Deep, rapid respirations (Kussmaul respirations) and lethargy are signs of diabetic ketoacidosis (DKA), which occurs in uncontrolled type 1 diabetes. Checking the blood glucose is the priority to confirm hyperglycemia and guide immediate treatment. Pulse oximetry is not the priority in this situation as the issue is related to altered glucose levels, not oxygenation. Arterial blood gases and serum electrolytes may be important later in the management of DKA but are not the initial priority compared to confirming and addressing the hyperglycemia.
3. The nurse is caring for a 5-year-old child with Reye’s syndrome. Which goal of treatment most clearly relates to caring for this child?
- A. Reduce cerebral edema and lower intracranial pressure
- B. Avert hypotension and septic shock
- C. Prevent cardiac arrhythmias and heart failure
- D. Promote kidney perfusion and normal blood pressure
Correct answer: A
Rationale: Reducing cerebral edema and lowering intracranial pressure is the primary goal of treatment for Reye’s syndrome.
4. Which of the following is a symptom of menopause?
- A. Bleeding per vagina
- B. Sleeping all the time
- C. Insomnia
- D. Increased concentration
Correct answer: C
Rationale: Insomnia is a common symptom of menopause. During menopause, hormonal changes can lead to sleep disturbances, including difficulty falling asleep or staying asleep. Choice A, 'Bleeding per vagina,' is not a typical symptom of menopause but should prompt further evaluation. Choice B, 'Sleeping all the time,' is not a common symptom of menopause; in fact, insomnia, rather than excessive sleep, is more prevalent. Choice D, 'Increased concentration,' is not a symptom of menopause; cognitive changes like forgetfulness or difficulty concentrating may occur, but increased concentration is not a typical manifestation.
5. A client with a history of peptic ulcer disease is admitted with severe epigastric pain. Which finding requires immediate intervention?
- A. Nausea and vomiting.
- B. Hematemesis.
- C. Melena.
- D. Rebound tenderness.
Correct answer: D
Rationale: In a client with a history of peptic ulcer disease presenting with severe epigastric pain, the finding that requires immediate intervention is rebound tenderness. Rebound tenderness can indicate peritonitis, a serious condition that necessitates immediate medical attention. Nausea and vomiting, hematemesis, and melena are also concerning symptoms in a client with a history of peptic ulcer disease, but they do not signify the urgency of intervention as rebound tenderness does.