HESI RN
HESI RN Exit Exam
1. The home health nurse is preparing to make daily visits to a group of clients. Which client should the nurse visit first?
- A. A client with congestive heart failure who reports a 3-pound weight gain in the last two days
- B. A client with a healing surgical wound
- C. A client requiring wound dressing change
- D. A client with stable vital signs needing medication administration
Correct answer: A
Rationale: The correct answer is A. A 3-pound weight gain in two days indicates fluid retention and worsening heart failure, which requires immediate assessment. This could be a sign of decompensation in the client's condition, necessitating prompt evaluation and intervention. Choices B, C, and D do not present an immediate threat to the client's health and can be addressed after assessing the client with congestive heart failure.
2. A client with a prescription for DNR begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?
- A. Inform the healthcare provider
- B. Determine the client's need for pain medication
- C. Begin comfort measures
- D. Ensure all life-saving equipment is removed
Correct answer: B
Rationale: The correct priority action for the nurse to implement in this scenario is to determine the client's need for pain medication. Ensuring that the client is comfortable and free from pain is crucial in end-of-life care, especially for a client with a Do Not Resuscitate (DNR) order. This action prioritizes the client's comfort and dignity in their final moments. While informing the healthcare provider and beginning comfort measures are important aspects of care, pain management takes precedence as the immediate priority. Removing life-saving equipment is not appropriate at this stage as it goes against the client's wishes stated in the DNR order.
3. Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client's right radial pulse. Which action should the nurse take first?
- A. Notify the healthcare provider of the finding immediately.
- B. Complete a neurovascular assessment of the right hand.
- C. Elevate the client's right hand on one or two pillows.
- D. Measure the client's blood pressure and apical pulse rate.
Correct answer: B
Rationale: Completing a neurovascular assessment of the right hand is the priority in this situation. This assessment will help determine the circulation, sensation, and movement of the affected limb, ensuring there are no complications like compartment syndrome or impaired perfusion. Notifying the healthcare provider immediately (Choice A) might be necessary but should come after assessing the client's neurovascular status. Elevating the client's right hand (Choice C) can be helpful in some cases but should not precede a neurovascular assessment. Measuring the client's blood pressure and apical pulse rate (Choice D) is important but not the priority when assessing a potential vascular compromise in the limb.
4. What action should be taken by the healthcare provider for a child who has ingested a corrosive product?
- A. Induce vomiting using Ipecac to remove the corrosive agent.
- B. Administer vinegar or lemon juice to neutralize the caustic agent.
- C. Give activated charcoal to decontaminate the stomach.
- D. Telephone the poison control center and follow their advice.
Correct answer: D
Rationale: In cases of corrosive product ingestion, it is crucial to contact the poison control center for guidance. Inducing vomiting or attempting to neutralize the agent can lead to further harm. The poison control center professionals are trained to provide specific instructions tailored to the situation, ensuring the best possible outcome for the child. Therefore, the correct action is to call the poison control center for appropriate advice. Inducing vomiting can cause additional damage by re-exposing the esophagus and mouth to the corrosive substance. Administering vinegar or lemon juice is not recommended as it may worsen the situation by causing a chemical reaction. While activated charcoal can be useful in some cases of poisoning, it is not recommended for corrosive substances as it is ineffective in binding to them.
5. A male client with rheumatoid arthritis is scheduled for a procedure in the morning. The procedure cannot be completed because of early morning stiffness. Which intervention should the nurse implement?
- A. Assign a UAP to assist the client with a warm shower early in the morning.
- B. Provide the client with a warm blanket to reduce stiffness.
- C. Delay the procedure until the client is less stiff.
- D. Encourage the client to perform range-of-motion exercises.
Correct answer: A
Rationale: A warm shower can help reduce morning stiffness, making the procedure more comfortable for the client. This intervention promotes comfort and mobility, addressing the immediate issue of stiffness. Providing a warm blanket (choice B) may offer some comfort but will not address the stiffness as effectively as a warm shower. Delaying the procedure (choice C) may inconvenience the client and not address the underlying stiffness issue. Encouraging range-of-motion exercises (choice D) is important for long-term management but may not provide immediate relief from the stiffness that is hindering the procedure.