HESI RN
HESI RN Exit Exam 2023
1. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which assessment finding requires immediate intervention?
- A. Use of accessory muscles
- B. Oxygen saturation of 90%
- C. Respiratory rate of 24 breaths per minute
- D. Blood pressure of 110/70 mmHg
Correct answer: A
Rationale: The correct answer is A: Use of accessory muscles. This finding indicates increased work of breathing in a client with COPD and may signal respiratory failure, requiring immediate intervention. In COPD, the use of accessory muscles suggests that the client is in distress and struggling to breathe effectively. Oxygen saturation of 90% is within an acceptable range for a client with COPD receiving supplemental oxygen and does not require immediate intervention. A respiratory rate of 24 breaths per minute is slightly elevated but not a critical finding. A blood pressure of 110/70 mmHg is within the normal range for an adult and does not indicate a need for immediate intervention in this scenario.
2. The client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which intervention should the nurse implement to ensure the client’s safety?
- A. Encourage the client to use oxygen continuously
- B. Monitor the client’s respiratory rate and effort
- C. Set the oxygen flow rate at 6 liters per minute
- D. Teach the client to avoid wearing wool blankets
Correct answer: B
Rationale: Monitoring the client’s respiratory rate and effort is essential to evaluate the effectiveness of oxygen therapy and prevent complications such as respiratory depression. This intervention helps the nurse promptly detect any deterioration in the client's respiratory status and take necessary actions to ensure the client's safety. Encouraging continuous oxygen use (Choice A) may lead to oxygen toxicity. Setting the oxygen flow rate at a specific level (Choice C) without individual assessment can be inappropriate and potentially harmful. Teaching the client to avoid wearing wool blankets (Choice D) is unrelated to the safe use of oxygen therapy.
3. When assessing an IV site used for fluid replacement and medication administration, the client complains of tenderness when the arm is touched above the site. Which additional assessment finding warrants immediate intervention by the nurse?
- A. Cool skin at the IV insertion site
- B. Presence of fluid leaking around the IV catheter
- C. Swelling above the IV site
- D. Red streaks tracking the vein
Correct answer: D
Rationale: The correct answer is D: "Red streaks tracking the vein." Red streaks indicate phlebitis, an inflammation of the vein that can lead to serious complications like infection or thrombophlebitis. Immediate intervention is required to prevent further damage. Choice A, cool skin at the IV insertion site, could indicate decreased circulation but is not as urgent as addressing phlebitis. Choice B, presence of fluid leaking around the IV catheter, may indicate infiltration or dislodgement of the catheter, requiring intervention but not as urgently as phlebitis. Choice C, swelling above the IV site, may suggest localized inflammation but doesn't pose an immediate threat like phlebitis does.
4. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which finding requires immediate intervention?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 24 breaths per minute
- C. Use of accessory muscles
- D. Blood pressure of 110/70 mmHg
Correct answer: C
Rationale: The correct answer is C. The use of accessory muscles indicates increased work of breathing and may signal respiratory failure in a client with COPD, requiring immediate intervention. Oxygen saturation of 90% is within an acceptable range for COPD patients on supplemental oxygen. A respiratory rate of 24 breaths per minute is slightly elevated but not an immediate concern. A blood pressure of 110/70 mmHg is within the normal range and does not require immediate intervention in this scenario.
5. An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take?
- A. Perform a 12-lead electrocardiogram
- B. Document in the client's record
- C. Notify the healthcare provider immediately
- D. Assess for signs of heart failure
Correct answer: B
Rationale: An S3 heart sound is often a normal finding in pregnant women due to increased blood volume and cardiac output. The nurse should document the finding as part of the routine assessment unless accompanied by other abnormal symptoms. Performing a 12-lead electrocardiogram (Choice A) is unnecessary for a normal S3 heart sound in pregnancy. Notifying the healthcare provider immediately (Choice C) is premature and may lead to unnecessary interventions. Assessing for signs of heart failure (Choice D) is not indicated as an isolated S3 heart sound is typically benign in pregnancy.