HESI RN
HESI 799 RN Exit Exam
1. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which intervention should the nurse implement first?
- A. Elevate the head of the bed.
- B. Administer oxygen therapy as prescribed.
- C. Assess the client's oxygen saturation.
- D. Obtain an arterial blood gas (ABG) sample.
Correct answer: C
Rationale: Assessing the client's oxygen saturation is the first priority in managing a client with COPD receiving supplemental oxygen to ensure adequate oxygenation. Monitoring oxygen saturation levels helps in determining the effectiveness of the oxygen therapy and if adjustments are needed. Elevating the head of the bed can help with breathing but is not the first priority. Administering oxygen therapy as prescribed is important, but assessing the current oxygen saturation comes before administering more oxygen. Obtaining an arterial blood gas (ABG) sample may provide valuable information, but it is not the initial intervention needed in this situation.
2. An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?
- A. K+ 3.4 mEq/L (3.4 mmol/L)
- B. Ca+2 7.8 mg/dL (1.95 mmol/L)
- C. Na+ 154 mEq/L (154 mmol/L)
- D. PO4-3 4.8 mg/dL (1.55 mmol/L)
Correct answer: C
Rationale: The correct answer is C. The elevated serum sodium level (154 mEq/L) is consistent with the patient's neurologic symptoms of restlessness, agitation, and weakness, indicating a need for immediate action to prevent complications like seizures. The potassium level (3.4 mEq/L) and calcium level (7.8 mg/dL) are slightly off from normal but do not require immediate action. The phosphate level (4.8 mg/dL) is normal and not related to the symptoms presented by the patient.
3. During the physical examination, Nurse Noah expects to assess which sign in a female client with a serum calcium level of 7.2 mg/dl?
- A. Trousseau's sign
- B. Homans' sign
- C. Hegar's sign
- D. Goodell's sign
Correct answer: A
Rationale: Trousseau's sign is a clinical indicator of hypocalcemia, characterized by carpal spasm when a blood pressure cuff is inflated above systolic pressure and maintained for a few minutes. This occurs due to increased neuromuscular irritability associated with low serum calcium levels. Homans' sign is used to assess for deep vein thrombosis and involves calf pain upon dorsiflexion of the foot. Hegar's sign is a softening of the lower uterine segment seen in pregnancy, while Goodell's sign is softening of the cervix also seen in pregnancy. Therefore, in this scenario, the correct assessment related to hypocalcemia would be Trousseau's sign.
4. The healthcare provider is assessing a child for neurological soft signs. Which finding is most likely demonstrated in the child's behavior?
- A. Inability to move the tongue in a specific direction.
- B. Presence of vertigo.
- C. Poor coordination and sense of position.
- D. Loss of visual acuity.
Correct answer: C
Rationale: Neurological soft signs in children often manifest as poor coordination and a sense of position. These signs can indicate underlying neurological issues and are important to assess in pediatric patients. Choices A, B, and D are less likely to be associated with neurological soft signs in children. Inability to move the tongue in a specific direction may suggest a cranial nerve dysfunction rather than general neurological soft signs. Presence of vertigo is more related to inner ear disturbances or vestibular issues. Loss of visual acuity may indicate problems with the eyes rather than general neurological soft signs.
5. A nurse is reinforcing teaching with a group of older adults about oil-rich foods. The nurse should include which of the following foods as the equivalent of 4 tsp of oil?
- A. 1 tbsp of soft margarine
- B. ½ oz of nuts
- C. 2 tbsp of peanut butter
- D. 1 oz of sunflower seeds
Correct answer: C
Rationale: The correct answer is C: 2 tbsp of peanut butter. Two tablespoons of peanut butter is approximately equivalent to 4 teaspoons of oil, providing healthy fats in the diet. Choice A, 1 tbsp of soft margarine, is not equivalent to 4 tsp of oil as margarine contains additional ingredients. Choice B, ½ oz of nuts, and choice D, 1 oz of sunflower seeds, do not provide an equivalent amount of oil as requested in the question.