HESI RN
HESI RN Exit Exam 2023
1. The nurse is assessing a client with left-sided heart failure. Which clinical finding requires immediate intervention?
- A. Jugular venous distention
- B. Shortness of breath
- C. Crackles in the lungs
- D. Peripheral edema
Correct answer: C
Rationale: Corrected Rationale: In a client with left-sided heart failure, crackles in the lungs are the most concerning finding as they indicate pulmonary congestion, which requires immediate intervention to prevent worsening heart failure symptoms and respiratory distress. Jugular venous distention, shortness of breath, and peripheral edema are also common in heart failure but are not as critical as crackles in the lungs because they may indicate fluid overload or right-sided heart failure, which are important to address but not as urgently as managing pulmonary congestion.
2. Following a lumbar puncture, a client complains of worsening headache when sitting up. What complication is the client likely experiencing?
- A. A migraine headache
- B. An infection from the puncture site
- C. Low blood sugar
- D. Spinal fluid leakage (post-lumbar puncture headache)
Correct answer: D
Rationale: The client is likely experiencing spinal fluid leakage (post-lumbar puncture headache), a common complication of a lumbar puncture. This leakage results in a reduction of cerebrospinal fluid volume around the brain and spinal cord, leading to a headache that worsens when in an upright position due to reduced buoyancy. A migraine headache (Choice A) is not typically associated with a lumbar puncture. Infection from the puncture site (Choice B) would present with localized signs of inflammation, such as redness, swelling, and warmth, rather than worsening headache. Low blood sugar (Choice C) is not a common complication of lumbar puncture and would not typically manifest as a worsening headache when sitting up.
3. Discuss the anatomical/physiological changes in pregnancy under the following: Kidney/renal system
- A. Kidneys increase in size, pelvis dilates, ureters elongate and dilate, and the glomerular filtration rate increases.
- B. Kidneys decrease in size, and glomerular filtration rate decreases.
- C. There is no change in kidney size or ureter function, but the glomerular filtration rate decreases.
- D. Kidneys shrink, and ureters remain the same.
Correct answer: A
Rationale: During pregnancy, the kidneys increase in size, the pelvis dilates, ureters elongate and dilate, and the glomerular filtration rate increases. This is due to the increased metabolic demands and hormonal changes during pregnancy. Choice B is incorrect as the kidneys do not decrease in size, and the glomerular filtration rate actually increases. Choice C is incorrect as there are changes in kidney size and ureter function during pregnancy. Choice D is incorrect as the kidneys do not shrink during pregnancy.
4. One hour after delivery, the nurse is unable to palpate the uterine fundus of a client and notes a large amount of lochia on the perineal pad. Which intervention should the nurse implement first?
- A. Empty the bladder using an indwelling urinary catheter
- B. Increase the rate of the IV containing oxytocin (Pitocin)
- C. Assess for shock by determining the blood pressure
- D. Perform gentle massage at the level of the umbilicus
Correct answer: D
Rationale: Gentle massage at the level of the umbilicus is the initial intervention to help contract the uterus and reduce bleeding, which is crucial in managing postpartum hemorrhage. Emptying the bladder can help with fundal displacement, but massage should be done first to stimulate uterine contractions. Increasing the IV oxytocin rate is a possible intervention but not the initial priority. Assessing for shock is important, but addressing the uterine atony through massage takes precedence to prevent further hemorrhage.
5. The nurse is caring for a client with pancreatitis who is receiving total parenteral nutrition (TPN). Which assessment finding requires immediate intervention by the nurse?
- A. Blood glucose level of 200 mg/dL
- B. The client reports feeling weak and shaky
- C. The TPN bag is 5% dextrose
- D. The client reports feeling thirsty
Correct answer: B
Rationale: The correct answer is B. Weakness and shakiness can indicate hypoglycemia, a potential complication of TPN. Immediate intervention is necessary to assess blood glucose levels and provide treatment as needed. Choice A is incorrect because a blood glucose level of 200 mg/dL is within an acceptable range and does not require immediate intervention. Choice C is incorrect as a 5% dextrose TPN bag is a standard concentration. Choice D is also incorrect as feeling thirsty is not a critical assessment finding requiring immediate intervention in this context.