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. The healthcare provider is assessing a client with left-sided heart failure. Which laboratory value should be monitored closely?
- A. Serum sodium of 135 mEq/L
- B. Serum potassium of 4.5 mEq/L
- C. Serum creatinine of 1.8 mg/dl
- D. Serum glucose of 200 mg/dl
Correct answer: C
Rationale: In a client with left-sided heart failure, monitoring serum creatinine is crucial to evaluate kidney function and fluid balance. Elevated creatinine levels can indicate impaired kidney function, which is common in heart failure due to decreased cardiac output and renal perfusion. Serum sodium levels (choice A) are important but are more closely associated with fluid balance and heart failure exacerbation. Serum potassium (choice B) is also important to monitor, but it is more closely linked to cardiac arrhythmias rather than kidney function. Serum glucose levels (choice D) are significant but are not the priority for monitoring in left-sided heart failure.
3. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which assessment finding requires immediate intervention?
- A. Barrel-shaped chest
- B. Use of accessory muscles
- C. Oxygen saturation of 85%
- D. Inspiratory crackles
Correct answer: C
Rationale: An oxygen saturation of 85% is significantly low for a client with COPD and requires immediate intervention to prevent hypoxemia. Oxygen saturation below 90% indicates poor oxygenation and poses a risk of tissue hypoxia, making it a critical finding that needs prompt attention. Barrel-shaped chest and inspiratory crackles are commonly seen in clients with COPD and do not necessitate immediate intervention. The use of accessory muscles may indicate increased work of breathing but does not pose the same level of immediate threat as severe hypoxemia.
4. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which finding requires immediate intervention?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 24 breaths per minute
- C. Use of accessory muscles
- D. Blood pressure of 110/70 mmHg
Correct answer: C
Rationale: The correct answer is C. The use of accessory muscles indicates increased work of breathing and may signal respiratory failure in a client with COPD, requiring immediate intervention. Oxygen saturation of 90% is within an acceptable range for COPD patients on supplemental oxygen. A respiratory rate of 24 breaths per minute is slightly elevated but not an immediate concern. A blood pressure of 110/70 mmHg is within the normal range and does not require immediate intervention in this scenario.
5. An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. After starting medication therapy, the nurse notices the client has more energy, is giving away her belongings, and has an elevated mood. Which intervention is best for the nurse to implement?
- A. Support the client by telling her what wonderful progress she is making.
- B. Ask the client if she has had any recent thoughts of harming herself.
- C. Reassure the client that the antidepressant drugs are apparently effective.
- D. Tell the client to keep her belongings because she will need them at discharge.
Correct answer: B
Rationale: When a client with major depressive disorder shows signs of increased energy, giving away belongings, and an elevated mood, it could indicate a shift towards suicidal behavior. Therefore, the best intervention for the nurse is to ask the client if she has had any recent thoughts of harming herself. This is crucial to assess the client's risk for suicide and provide necessary interventions. Choices A, C, and D are incorrect because they do not address the potential risk of harm to the client and do not prioritize the immediate assessment required in this situation.
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