HESI RN
HESI RN Exit Exam 2023
1. The charge nurse of the critical care unit informed at the beginning of the shift that a less than optimal number of registered nurses would be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse?
- A. A 34-year-old admitted today after an emergency appendectomy who has a peripheral intravenous catheter and a Foley catheter.
- B. A 48-year-old marathon runner with a central venous catheter experiencing nausea and vomiting due to electrolyte disturbance following a race.
- C. A 63-year-old chain smoker with chronic bronchitis receiving oxygen via nasal cannula and a saline-locked peripheral intravenous catheter.
- D. An 82-year-old client with Alzheimer's disease and a newly fractured femur with a Foley catheter and soft wrist restraints applied.
Correct answer: D
Rationale: The 82-year-old client with Alzheimer's disease and a newly fractured femur should receive the most care hours by a registered nurse because they are at the highest risk for injury and complications. The client's age, diagnosis of Alzheimer's disease, and the presence of a newly fractured femur along with the Foley catheter and wrist restraints indicate a need for close monitoring and care. Choice A is less critical as the client is stable post-appendectomy. Choice B, though experiencing symptoms, is not at the same level of risk as the client in Choice D. Choice C, while requiring oxygen support, does not have the same level of acuity and complexity as the client in Choice D.
2. Which of the following lab values would be most concerning in a patient receiving heparin therapy?
- A. Elevated hemoglobin levels.
- B. Low platelet count.
- C. High potassium levels.
- D. Low sodium levels.
Correct answer: B
Rationale: A low platelet count is most concerning in patients receiving heparin therapy due to the risk of heparin-induced thrombocytopenia. Heparin can sometimes cause a drop in platelet count, leading to a potentially serious condition where blood does not clot as it should. This can result in excessive bleeding or clot formation in blood vessels. Elevated hemoglobin levels, high potassium levels, and low sodium levels are not typically associated with heparin therapy and are less likely to cause immediate concerns or complications in this context.
3. The parents of a 4-year-old child who has just been diagnosed with celiac disease are being educated by a healthcare provider. Which statement by the parents indicates a correct understanding of the condition?
- A. We can give our child small amounts of gluten occasionally
- B. We need to avoid giving our child foods containing wheat, barley, and rye
- C. We should limit our child’s intake of dairy products
- D. Our child will need to take gluten-free supplements
Correct answer: B
Rationale: Choice B is the correct answer because for individuals with celiac disease, a strict gluten-free diet is essential for managing the condition. Foods containing wheat, barley, and rye must be completely avoided to prevent adverse reactions and damage to the intestines. This dietary restriction is crucial to ensure the child's health and well-being in managing celiac disease effectively. Choices A, C, and D are incorrect because giving small amounts of gluten occasionally, limiting dairy products, or taking gluten-free supplements are not sufficient measures to manage celiac disease. Complete avoidance of gluten-containing foods is necessary to prevent complications.
4. A nurse is reinforcing teaching with a client about dietary choices for celiac disease. Which of the following menu choices selected by the client indicates an understanding of the teaching?
- A. Hamburger on a wheat bun
- B. Baked chicken and potato chips
- C. Bacon, lettuce, and tomato sandwich on rye toast
- D. Beef and barley soup with crackers
Correct answer: B
Rationale: The correct answer is B because baked chicken and potato chips are gluten-free options suitable for a client with celiac disease. Choice A, a hamburger on a wheat bun, contains gluten, which is harmful to individuals with celiac disease. Choice C, a bacon, lettuce, and tomato sandwich on rye toast, also contains gluten. Choice D, beef and barley soup with crackers, includes gluten from the barley and crackers, making it unsuitable for someone with celiac disease.
5. A client with heart failure is experiencing shortness of breath and swelling in the legs. What is the nurse's priority intervention?
- A. Administer prescribed diuretics
- B. Place the client in a supine position
- C. Restrict fluid intake immediately
- D. Increase the client's sodium intake
Correct answer: A
Rationale: The correct answer is A: Administer prescribed diuretics. Diuretics are prescribed to reduce fluid overload in clients with heart failure. By promoting urine output, diuretics help alleviate symptoms like shortness of breath and swelling. While placing the client in a supine position can help with breathing and fluid redistribution, administering diuretics takes precedence as it directly addresses fluid overload. Restricting fluid intake immediately may be necessary in some cases, but the immediate priority is to administer diuretics. Increasing the client's sodium intake would worsen fluid retention and is contraindicated in heart failure.