HESI RN
HESI RN Exit Exam 2023
1. The healthcare provider is assessing a client with left-sided heart failure. Which laboratory value should be closely monitored?
- A. Serum sodium level
- B. Serum potassium level
- C. Serum creatinine level
- D. Serum glucose level
Correct answer: B
Rationale: In a client with left-sided heart failure, monitoring serum potassium levels is crucial. This helps in assessing kidney function and fluid balance. Elevated potassium levels can result from impaired kidney function, which is common in heart failure. Monitoring sodium levels (choice A) is important in heart failure but not specifically related to left-sided heart failure. Serum creatinine (choice C) reflects kidney function but is not the most critical value to monitor in this case. Serum glucose level (choice D) is important but not the priority when assessing left-sided heart failure.
2. The client is weak from inactivity due to a 2-week hospitalization. In planning care for the client, which range of motion (ROM) exercises should the nurse include?
- A. Passive ROM exercises to all joints on all extremities four times a day.
- B. Active ROM exercises to both arms and legs two or three times a day.
- C. Active ROM exercises with weights twice a day, 20 repetitions each.
- D. Passive ROM exercises to the point of resistance and slightly beyond.
Correct answer: B
Rationale: Active ROM exercises are preferred over passive ROM to restore strength. Performing them on both arms and legs two or three times a day is effective in promoting muscle strength and mobility without the need for external assistance. Choice A is incorrect as passive ROM exercises may not help in restoring strength. Choice C is not recommended as using weights may be too strenuous for a weak client. Choice D is incorrect as passive ROM exercises to the point of resistance and slightly beyond may cause discomfort or injury to the weak client.
3. A client with type 1 diabetes mellitus presents to the emergency department with symptoms of diabetic ketoacidosis (DKA). Which of the following interventions should the nurse implement first?
- A. Administer intravenous insulin
- B. Start an intravenous line and infuse normal saline
- C. Monitor serum potassium levels
- D. Obtain an arterial blood gas (ABG)
Correct answer: B
Rationale: The correct first intervention in a client with DKA is to start an intravenous line and infuse normal saline for fluid resuscitation. This is crucial to restore intravascular volume and improve perfusion, addressing the dehydration and electrolyte imbalances commonly seen in DKA. Administering insulin without addressing the dehydration can lead to further complications. Monitoring serum potassium levels is important but is not the first priority; potassium levels can shift with fluid resuscitation. Obtaining an arterial blood gas (ABG) is helpful in assessing acid-base status but is not the initial priority compared to fluid resuscitation.
4. The nurse is performing an admission assessment of an older client who has difficulty swallowing and has a history of aspiration pneumonia. Which action should the nurse implement first?
- A. Obtain a speech therapy consult
- B. Elevate the head of the bed
- C. Check the client's lung sounds
- D. Implement aspiration precautions
Correct answer: B
Rationale: The correct action for the nurse to implement first is to elevate the head of the bed. Elevating the head of the bed helps prevent aspiration in clients with swallowing difficulties by reducing the risk of food or fluids entering the airway. While obtaining a speech therapy consult (Choice A) is important, the immediate priority is to ensure the client's safety by positioning them properly. Checking the client's lung sounds (Choice C) and implementing aspiration precautions (Choice D) are also essential steps but should follow the immediate intervention of elevating the head of the bed to prevent aspiration.
5. A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement?
- A. Isolate the client from the other clients.
- B. Administer a PRN sedative.
- C. Avoid recognizing the behavior.
- D. Escort the client to his room.
Correct answer: C
Rationale: The correct intervention for the RN to implement in this situation is to avoid recognizing the behavior. By not reinforcing the echolalia through recognition, the behavior is less likely to be perpetuated, and it can reduce annoyance to other clients on the unit. Isolating the client may lead to feelings of rejection and exacerbate the behavior. Administering a PRN sedative should not be the first line of intervention for echolalia, as it does not address the underlying cause. Escorting the client to his room does not actively address the behavior or provide a therapeutic response.