HESI RN
HESI RN Exit Exam
1. Sublingual nitroglycerin is administered to a male client with unstable angina who complains of crushing chest pain. Five minutes later the client becomes nauseated, and his blood pressure drops to 60/40. Which intervention should the nurse implement?
- A. Administer a second dose of nitroglycerin.
- B. Infuse a rapid IV normal saline bolus.
- C. Begin external chest compressions.
- D. Give a PRN antiemetic medication.
Correct answer: B
Rationale: In this scenario, the client's symptoms of nausea and a significant drop in blood pressure suggest a potential right ventricular infarction. The appropriate intervention for this situation is to infuse a rapid IV normal saline bolus. This fluid resuscitation helps improve cardiac output by increasing preload, which can be beneficial in right ventricular infarction. Administering a second dose of nitroglycerin may further lower blood pressure. External chest compressions are not indicated in this case as the client has a pulse. Providing an antiemetic medication does not address the underlying issue of hypotension and potential right ventricular involvement.
2. The nurse is providing care for a client with a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse implement to prevent complications associated with the tube?
- A. Elevate the head of the bed to 15 degrees during feedings
- B. Aspirate gastric contents before administering medications
- C. Clamp the tube between feedings
- D. Flush the tube with water before and after feedings
Correct answer: D
Rationale: Flushing the PEG tube with water before and after feedings helps prevent clogging and maintains tube patency. Proper flushing is essential for avoiding complications related to tube blockages. Elevating the head of the bed is important for preventing aspiration during and after feedings, not specifically related to PEG tube complications. Aspirating gastric contents before administering medications is not routinely recommended for PEG tube care. Clamping the tube between feedings can lead to tube occlusion and is not a standard practice in PEG tube care.
3. A new mother calls the nurse stating that she wants to start feeding her 6-month-old child something besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse respond?
- A. Advise the mother to wait at least another month before starting any solid foods.
- B. Instruct the mother to offer a few spoons of 2 or 3 pureed fruits at each meal.
- C. Reassure the mother that the infant is old enough to eat iron-fortified cereal.
- D. Encourage the mother to schedule a developmental assessment of the infant.
Correct answer: C
Rationale: At 6 months, infants are generally ready to start eating iron-fortified cereals as their iron stores begin to deplete. Introducing iron-fortified cereals at this age helps meet the infant's nutritional needs, particularly for iron, which becomes deficient as the infant's iron reserves diminish. It is a safe and appropriate first food to introduce to infants around 6 months of age, along with continued breastfeeding or formula feeding. Choice A is incorrect because waiting another month is not necessary if the infant is 6 months old. Choice B is incorrect as introducing pureed fruits as the first food may not provide the necessary iron that the infant needs at this stage. Choice D is also incorrect as scheduling a developmental assessment is not indicated solely based on the desire to start solid foods; it is more appropriate to reassure the mother about starting iron-fortified cereal.
4. The father of an 11-year-old client reports to the nurse that the client has been 'wetting the bed' since the passing of his mother and is concerned. Which action is most important for the nurse to take?
- A. Reassure the father that it is normal for a child to wet the bed after a traumatic event
- B. Inform the father that nocturnal emissions are abnormal and his son is developmentally delayed
- C. Inform the father that it is crucial to let the son know that bedwetting is a normal response to trauma
- D. Refer the father and the client to a psychologist
Correct answer: C
Rationale: Bedwetting after trauma, such as losing a parent, is common in children. The nurse should inform the father that it is crucial to let the son know that bedwetting is a normal response to trauma. Reassurance and understanding are essential in addressing the child's emotional needs during this difficult time. Choice A is incorrect as it focuses on puberty rather than trauma as the underlying cause. Choice B is incorrect as it provides inaccurate information about nocturnal emissions and developmental delay. Choice D is premature as the first step should be to provide education and support before considering a referral to a psychologist.
5. A client with chronic obstructive pulmonary disease (COPD) presents with a respiratory rate of 32 breaths per minute and an oxygen saturation of 86%. What is the nurse's first action?
- A. Administer oxygen at 2 L/min via nasal cannula.
- B. Notify the healthcare provider immediately.
- C. Position the client in high Fowler's position.
- D. Suction the client's airway.
Correct answer: A
Rationale: Administering oxygen at 2 L/min via nasal cannula is the nurse's first action when a client with COPD presents with a respiratory rate of 32 breaths per minute and an oxygen saturation of 86%. Oxygen therapy helps improve oxygen saturation in patients with COPD and respiratory distress. While notifying the healthcare provider is important, immediate intervention to improve oxygenation takes priority. Positioning the client in high Fowler's position can also assist with breathing but is not the initial action in this scenario. Suctioning the airway is not indicated unless there are secretions obstructing the airway, which is not mentioned in the scenario.