the nurse weighs a 6 month old infant during a well baby check up and determines that the babys weight has tripled compared to the birth weight of 7 p
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Nursing Elites

HESI RN

RN HESI Exit Exam

1. The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby's weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer?

Correct answer: A

Rationale: The correct answer is A: 'Your baby is gaining weight right on schedule.' Tripling of birth weight by 6 months is a normal growth pattern in infants, indicating appropriate weight gain and development. Choice B is unrelated to the question as it focuses on the baby's diet rather than addressing the weight gain concern. Choice C is incorrect as tripling the birth weight is considered a healthy growth pattern, not below normal percentile. Choice D is irrelevant to the mother's question about the adequacy of weight gain.

2. At 0600 while admitting a woman for a scheduled repeat cesarean section (C-Section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

Correct answer: C

Rationale: The correct action for the nurse to take first is to inform the anesthesia care provider. The patient's ingestion of coffee violates the NPO (nothing by mouth) guidelines before surgery, which increases the risk of aspiration during anesthesia. Informing the anesthesia care provider promptly allows for appropriate assessment and decision-making regarding the patient's anesthesia plan. Ensuring preoperative lab results, starting an IV, or contacting the obstetrician can be important steps but addressing the NPO violation and its implications on anesthesia safety take precedence.

3. An adult male who fell from a roof and fractured his left femur is admitted for surgical stabilization after having a soft cast applied in the emergency department. Which assessment finding warrants immediate intervention by the nurse?

Correct answer: A

Rationale: In a patient with a fractured femur, weak palpable distal pulses can indicate compromised circulation to the lower extremity. This finding suggests a potential vascular compromise that requires immediate intervention to prevent further complications like compartment syndrome or ischemia. Pain at the fracture site, mild swelling of the leg, and bruising around the fracture site are expected following such an injury and surgical stabilization, and while they should be monitored, they do not require immediate intervention like addressing compromised circulation.

4. A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which laboratory value is most concerning?

Correct answer: C

Rationale: In a client with hyperglycemic hyperosmolar syndrome (HHS), a serum osmolarity of 320 mOsm/kg is the most concerning laboratory value. This high osmolarity indicates severe dehydration, which can lead to serious complications. Elevated serum glucose levels (choice A) are expected in HHS but do not directly reflect dehydration. Blood pressure (choice B) and serum pH (choice D) are important parameters to monitor but are not the most concerning values in HHS compared to serum osmolarity.

5. A client with a history of rheumatoid arthritis is prescribed prednisone. Which assessment finding requires immediate intervention?

Correct answer: B

Rationale: The correct answer is B. Weight gain of 2 pounds in 24 hours is concerning in a client with rheumatoid arthritis on prednisone as it may indicate fluid retention or worsening heart failure. Increased joint pain, blood glucose level of 150 mg/dl, and fever of 100.4°F are important assessments but do not require immediate intervention compared to the potential severity of rapid weight gain.

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