HESI RN
HESI 799 RN Exit Exam
1. While auscultating a client's heart sounds, which description should the nurse use to document a swishing sound related to blood turbulence or valvular defect?
- A. S1 S2
- B. S1 S2 S3
- C. Murmur
- D. Pericardial friction rub
Correct answer: C
Rationale: The correct answer is 'C: Murmur.' A murmur is auscultated as a swishing sound associated with blood turbulence caused by the heart or a valvular defect. Choices 'A: S1 S2' and 'B: S1 S2 S3' refer to normal heart sounds, specifically the closure of heart valves. 'D: Pericardial friction rub' is a dry, rubbing or grating sound caused by inflammation of the pericardial sac and is not associated with blood flow or valvular issues.
2. A healthcare provider caring for a client with severe malnutrition reviews the laboratory results and notes a magnesium level of 1.0 mg/dL. Which electrocardiographic change would the healthcare provider expect to note based on the magnesium level?
- A. Prominent U waves
- B. Prolonged PR interval
- C. Depressed ST segment
- D. Widened QRS complexes
Correct answer: C
Rationale: A magnesium level of 1.0 mg/dL can cause a depressed ST segment on the ECG. Magnesium deficiency commonly leads to ST segment depression on an electrocardiogram. Prominent U waves are associated with hypokalemia, prolonged PR interval is seen in conditions like first-degree heart block, and widened QRS complexes are typically related to conditions affecting the conduction system of the heart, such as bundle branch blocks.
3. Which of the following actions by the healthcare provider would be considered false imprisonment?
- A. The healthcare provider tells the client they are not allowed to leave until the physician has released them.
- B. The healthcare provider asks the client why they wish to leave.
- C. The healthcare provider asks the client to explain what they understand about their medical diagnosis.
- D. The healthcare provider asks the client to sign an against medical advice discharge form.
Correct answer: A
Rationale: The correct answer is A. False imprisonment occurs when a healthcare provider restrains a client from leaving against their will, even if the provider believes it is in the client's best interest. In this scenario, telling the client they are not allowed to leave until the physician has released them constitutes false imprisonment as it restricts the client's freedom of movement. Choice B is incorrect because asking the client why they wish to leave is a form of assessment and does not involve restraining the client. Choice C is incorrect as it pertains to educating the client about their medical condition. Choice D is incorrect because asking the client to sign an against medical advice discharge form is a legal and ethical procedure to ensure the client understands the risks of leaving against medical advice.
4. When culturing a wound, the nurse should obtain the sample from which part of the wound?
- A. The outer edges of the wound.
- B. All necrotic sections of the wound.
- C. Areas containing purulent or pooled exudates.
- D. Any particularly painful area of the wound.
Correct answer: C
Rationale: To collect a wound culture, the nurse should first clean the wound to remove skin flora and then insert a sterile swab from a culturette tube into the wound secretions.
5. A client is being monitored while receiving bethanechol chloride (Urecholine) for urinary retention. Which of the following indicates a therapeutic effect of this medication?
- A. Increased heart rate
- B. Increased peristalsis
- C. Passage of flatus
- D. Urinary output of 50 mL per hour
Correct answer: D
Rationale: Bethanechol chloride (Urecholine) is administered to stimulate the bladder and treat urinary retention. The therapeutic effect is indicated by an increased urinary output, as it demonstrates the medication's ability to prompt the bladder to empty. Increased heart rate and passage of flatus are unrelated to the therapeutic effects of bethanechol. Although bethanechol can increase peristalsis, the primary therapeutic goal is to address urinary retention.