HESI RN
HESI RN Exit Exam
1. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which assessment finding requires immediate intervention?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 24 breaths per minute
- C. Use of accessory muscles
- D. Inspiratory crackles
Correct answer: C
Rationale: The correct answer is C. The use of accessory muscles is most concerning in a client with COPD receiving supplemental oxygen as it indicates increased work of breathing, requiring immediate intervention. Oxygen saturation of 90% is acceptable in a client with COPD. A respiratory rate of 24 breaths per minute is slightly elevated but not as critical as the use of accessory muscles. Inspiratory crackles may be present in clients with COPD due to underlying lung changes but do not require immediate intervention unless associated with other concerning symptoms.
2. A client with atrial fibrillation is receiving digoxin (Lanoxin) and warfarin (Coumadin). Which assessment finding should the nurse report to the healthcare provider immediately?
- A. Heart rate of 58 beats per minute
- B. Presence of a new murmur
- C. INR of 2.5
- D. Blood pressure of 110/70 mmHg
Correct answer: B
Rationale: The correct answer is B. The presence of a new murmur in a client with atrial fibrillation may indicate a valvular problem or other complications, requiring immediate reporting. A heart rate of 58 beats per minute is within the normal range for some individuals with atrial fibrillation, so it is not an immediate concern. An INR of 2.5 is within the therapeutic range for a client on warfarin, indicating appropriate anticoagulation. A blood pressure of 110/70 mmHg is also within the normal range and does not pose an immediate threat to the client's health.
3. The nurse is caring for a client with diabetic ketoacidosis (DKA). Which intervention is most important?
- A. Administer insulin as prescribed.
- B. Monitor the client's urine output.
- C. Assess the client's level of consciousness.
- D. Obtain an arterial blood gas (ABG) sample.
Correct answer: A
Rationale: Administering insulin is the most crucial intervention in managing diabetic ketoacidosis. Insulin helps reduce blood glucose levels and correct metabolic acidosis, which are the primary issues in DKA. Monitoring urine output (Choice B) is important but not as critical as administering insulin. Assessing the client's level of consciousness (Choice C) is essential but does not directly address the underlying cause of DKA. Obtaining an arterial blood gas sample (Choice D) can provide valuable information but is not as urgent as administering insulin to address the immediate metabolic imbalance.
4. After checking the fingerstick glucose at 1630, what action should be implemented?
- A. Notify the healthcare provider.
- B. Administer 8 units of insulin aspart SubQ.
- C. Give an IV bolus of Dextrose 50% 50 ml.
- D. Perform quality control on the glucometer.
Correct answer: B
Rationale: Administering insulin aspart (rapid-acting insulin) is the appropriate action to manage the elevated glucose level of 1630. Choice A, notifying the healthcare provider, is not the immediate action needed for this glucose level. Choice C, giving an IV bolus of Dextrose 50%, would exacerbate hyperglycemia instead of treating it. Choice D, performing quality control on the glucometer, is not relevant to the management of the patient's glucose level at this time.
5. 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.
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