the nurse who is working on a surgical unit receives a change of shift report on a group of clients for the upcoming shift a client with which conditi
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Nursing Elites

HESI RN

HESI RN Exit Exam

1. The nurse who is working on a surgical unit receives a change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?

Correct answer: D

Rationale: The correct answer is D. A client who had an abdominal-perineal resection 2 days ago with no drainage on the dressing but is presenting with fever and chills requires immediate attention. This presentation raises concerns for peritonitis, a serious complication that necessitates prompt assessment and intervention to prevent further complications. Choices A, B, and C do not indicate an immediate risk for a life-threatening condition like peritonitis, making them lower priority compared to choice D.

2. A male client is having abdominal pain after a left femoral angioplasty and stent, and is asking for additional pain medication for right lower quadrant pain (9/10). Two hours ago, he received hydrocodone/acetaminophen 7.5/325 mg. His vital signs are elevated from previous readings: temperature 97.8°F, heart rate 102 beats/minute, respiration 20 breaths/minute. His abdomen is swollen, the groin access site is tender, peripheral pulses are present, but the left is greater than the right. What data is needed to make this report complete?

Correct answer: B

Rationale: The correct answer is B. In this scenario, the client is experiencing abdominal pain after a left femoral angioplasty and stent, with signs of potential complications such as a swollen abdomen, tenderness at the groin access site, and unequal peripheral pulses. The client's vital signs are also elevated, indicating a worsening condition. Given these findings, the immediate evaluation by the surgeon is crucial to assess for serious complications like internal bleeding or ischemia. Choice A is incorrect as the focus should be on the urgent need for surgical evaluation rather than lung sounds and oxygen saturation. Choice C is irrelevant to the immediate management of the client's current situation. Choice D, while providing background information, is not essential for the urgent intervention required in this case.

3. During the infusion of a second unit of packed red blood cells, the client's temperature increases from 99 to 101.6 F. Which intervention should the nurse implement?

Correct answer: A

Rationale: An increase in temperature during a transfusion may indicate a transfusion reaction, which can be serious. Stopping the transfusion and starting a saline infusion is the priority action to prevent further complications and address the potential adverse reaction. Administering antipyretics (choice B) may mask the symptoms of a transfusion reaction, delaying appropriate treatment. While monitoring vital signs (choice C) is important, stopping the transfusion takes precedence to prevent harm. Notifying the healthcare provider (choice D) is essential but should not delay the immediate intervention of stopping the transfusion and starting a saline infusion.

4. A female client reports that she drank a liter of a solution to cleanse her intestines but vomited immediately. How many ml of fluid intake should the nurse document?

Correct answer: C

Rationale: The correct answer is 760 ml. After vomiting 240 ml (1 cup), the nurse should document the remaining 760 ml as the fluid intake. Choice A (240 ml) is the amount vomited, not the total intake. Choice B (500 ml) and Choice D (1000 ml) are the total intake, not considering the vomiting.

5. An adult female client is admitted to the psychiatric unit because of a complex handwashing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior?

Correct answer: C

Rationale: The client’s handwashing ritual is a compulsion, a repetitive behavior driven by the need to reduce anxiety associated with an obsession. In this case, the client's need to wash her hands excessively stems from an obsession with cleanliness, leading to the compulsive behavior of extensive handwashing. 'Addiction' (Choice A) involves a dependence on a substance or behavior, not related to this scenario. 'Phobia' (Choice B) is an intense fear of a specific object or situation, not applicable here. 'Obsession' (Choice D) refers to persistent and intrusive thoughts, while the handwashing behavior in this case is the compulsive action taken to alleviate the anxiety related to the obsession.

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