the charge nurse observes a new nurse preparing to insert an intravenous iv catheter the new nurse has gathered supplies including intravenous cathete
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Nursing Elites

HESI RN

HESI RN Exit Exam

1. The charge nurse observes a new nurse preparing to insert an intravenous (IV) catheter. The new nurse has gathered supplies, including intravenous catheters, an intravenous insertion kit, and a 4x4 sterile gauze dressing to cover and secure the insertion site. What action should the charge nurse take?

Correct answer: A

Rationale: The correct answer is to instruct the nurse to use a transparent dressing over the site. Transparent dressings allow for continuous observation of the IV site, reducing the risk of complications. Choice B is incorrect because the charge nurse should intervene to ensure the new nurse follows best practices. Choice C is incorrect as the charge nurse should not just assist but provide guidance on the correct procedure. Choice D is incorrect because the size of the dressing is not the issue; it's the type of dressing that allows for better observation.

2. A client with cirrhosis is admitted with ascites and jaundice. Which clinical finding is most concerning?

Correct answer: C

Rationale: The correct answer is C. Confusion and altered mental status are the most concerning clinical findings in a client with cirrhosis because they may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Peripheral edema (choice A) and increased abdominal girth (choice B) are common manifestations of cirrhosis but are not as acutely concerning as signs of hepatic encephalopathy. Yellowing of the skin (choice D) is due to jaundice, which is already present in the client and does not directly indicate a worsening condition like confusion and altered mental status.

3. A client with a history of hypertension is admitted with a blood pressure of 200/110 mmHg. Which intervention should the nurse implement first?

Correct answer: D

Rationale: The correct answer is to obtain an arterial blood gas (ABG) sample. In a client with severe hypertension, it is essential to assess for metabolic or respiratory acidosis which can be done through an ABG sample. Administering antihypertensive medication without assessing the acid-base status of the client can lead to potential complications. Monitoring urine output and administering oxygen therapy are important interventions but are not the priority in this situation where the focus should be on assessing acidosis.

4. The nurse is preparing to administer an intramuscular injection to a client with muscle wasting in the gluteal region. What is the most appropriate site for the injection?

Correct answer: D

Rationale: The vastus lateralis site is the most appropriate for an IM injection in a client with muscle wasting in the gluteal region. Administering the injection in the vastus lateralis ensures effective medication delivery due to muscle wasting in the gluteal region, preventing potential complications associated with the dorsogluteal or ventrogluteal sites, which may not be suitable in this specific client case. The deltoid site is mainly used for smaller volumes of medication and may not be ideal for this scenario.

5. A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which laboratory value requires immediate intervention?

Correct answer: B

Rationale: A serum osmolarity of 320 mOsm/kg is concerning in a client with HHS because it indicates severe dehydration and hyperosmolarity, which requires immediate intervention. In HHS, the elevated serum osmolarity leads to neurological symptoms and can result in serious complications if not addressed promptly. While a high serum glucose level (choice A) is typical in HHS, the osmolarity is a more direct indicator of dehydration and severity. Serum sodium (choice C) and potassium levels (choice D) are important but do not pose an immediate threat to the client's condition compared to the severe hyperosmolarity indicated by a high serum osmolarity level.

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