HESI RN
HESI RN Exit Exam 2023
1. The nurse is caring for a client with a history of myocardial infarction who is experiencing chest pain. Which intervention should the nurse implement first?
- A. Administer oxygen therapy as prescribed.
- B. Obtain an electrocardiogram (ECG).
- C. Administer nitroglycerin sublingually as prescribed.
- D. Administer aspirin as prescribed.
Correct answer: A
Rationale: Administering oxygen therapy is the priority intervention in managing chest pain in a client with a history of myocardial infarction. Oxygen helps improve oxygenation to the heart muscle, which is crucial in reducing further damage. Obtaining an electrocardiogram (ECG) is important to assess for changes indicative of myocardial infarction, but providing oxygen takes precedence as it directly addresses the physiological need for oxygen. Administering nitroglycerin and aspirin are important interventions but are typically implemented after oxygen therapy to address vasodilation and antiplatelet effects, respectively.
2. At what age are women likely to enter menopause?
- A. 35 - 40 years
- B. 40 - 45 years
- C. 45 - 50 years
- D. 25 - 30 years
Correct answer: C
Rationale: Women generally enter menopause between the ages of 45 - 50 years. During this stage, women experience a decline in estrogen production, leading to the cessation of menstrual cycles. Choices A, B, and D are incorrect as they do not fall within the typical age range for menopause onset. Menopause typically occurs later in life, around the age of 45 to 50 years, although individual variations exist.
3. A client is receiving dietary instructions from a nurse regarding warfarin sodium (Coumadin) therapy. The nurse advises the client to avoid which food item?
- A. Grapes
- B. Spinach
- C. Watermelon
- D. Cottage cheese
Correct answer: B
Rationale: The correct answer is B: Spinach. Spinach is high in vitamin K, which antagonizes the effects of warfarin sodium, an anticoagulant medication. Clients taking warfarin should avoid consuming foods rich in vitamin K, like spinach, to maintain the medication's effectiveness. Grapes (choice A), watermelon (choice C), and cottage cheese (choice D) do not interfere with the effects of warfarin, so they are safe for the client to consume while on warfarin therapy.
4. Which animal is an ovoviviparous animal?
- A. Basking shark
- B. Bonobo
- C. Blue shark
- D. None of the above
Correct answer: C
Rationale: The correct answer is the Blue shark. Ovoviviparous animals produce eggs that develop inside the body of the parent, and the offspring are born alive. The basking shark does not fall under this category as it is ovoviviparous, meaning it lays eggs that hatch inside the female's body. The bonobo is a separate species and not relevant to the question.
5. The nurse is planning care for a 2-year-old child who is scheduled for an infusion of immune globulin for treatment of idiopathic thrombocytopenic purpura (ITP). Which nursing diagnosis has the highest priority for this child?
- A. Risk for infection
- B. Risk for injury
- C. Altered oral mucous membranes
- D. Risk for fluid volume deficit
Correct answer: A
Rationale: The correct answer is 'Risk for infection.' When caring for a child with ITP scheduled for immune globulin infusion, the highest priority is to prevent infection. This is crucial due to the risk of bleeding associated with ITP and the immunosuppression that can be caused by the condition and its treatment. The other options, such as 'Risk for injury,' 'Altered oral mucous membranes,' and 'Risk for fluid volume deficit,' are not as high a priority as preventing infection in this particular situation.