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?
- A. Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing.
- B. Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson-Pratt drain.
- C. Collapsed lung after a fall 8 hours ago with 100 ml blood in the chest tube collection container
- D. Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills.
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 community health nurse is evaluating the effectiveness of a recent smoking cessation program. Which outcome indicates success?
- A. increased attendance at support group meetings
- B. reduced number of cigarettes smoked per day
- C. higher sales of nicotine replacement products
- D. lower relapse rate among participants
Correct answer: D
Rationale: The correct answer is D: lower relapse rate among participants. A lower relapse rate indicates that participants are successfully quitting smoking and maintaining their cessation, which is the ultimate goal of a smoking cessation program. Increased attendance at support group meetings (choice A) may demonstrate engagement but does not necessarily indicate successful smoking cessation. Similarly, higher sales of nicotine replacement products (choice C) may reflect increased product usage but not necessarily successful smoking cessation. While reducing the number of cigarettes smoked per day (choice B) is a positive change, it does not guarantee successful smoking cessation or long-term abstinence.
3. A nursing student is suctioning a client through a tracheostomy tube while a nurse observes. Which action by the student would prompt the nurse to intervene and demonstrate the correct procedure? Select all that apply.
- A. Setting the suction pressure to 60 mm Hg
- B. Applying suction throughout the procedure
- C. Assessing breath sounds before suctioning
- D. Placing the client in a supine position before the procedure
Correct answer: A
Rationale: The correct suction pressure for an adult client with a tracheostomy tube is typically between 80 to 120 mm Hg. Suction should be applied intermittently during catheter withdrawal to avoid damaging the airway. Assessing breath sounds before suctioning is important to ensure the procedure is necessary. Placing the client in a supine position before suctioning can compromise their airway; instead, the head of the bed should be elevated to facilitate proper drainage and reduce the risk of aspiration. Therefore, setting the suction pressure to 60 mm Hg is incorrect and would prompt the nurse to intervene and correct the procedure.
4. Oxygen via nasal cannula has been prescribed for a client with emphysema. The nurse checks the physician’s orders to ensure that the prescribed flow is not greater than:
- A. 1 L/min
- B. 3 L/min
- C. 4 L/min
- D. 6 L/min
Correct answer: B
Rationale: The correct answer is B, 3 L/min. Clients with emphysema typically receive oxygen at a flow rate of 1 to 2 L/min, with a maximum of 3 L/min. Higher flow rates can lead to oxygen toxicity in these clients, so it's crucial to adhere to the prescribed limits. Choice A (1 L/min) is too low and may not provide adequate oxygenation for the client. Choices C (4 L/min) and D (6 L/min) exceed the recommended flow rates for clients with emphysema and can increase the risk of oxygen toxicity.
5. A client with heart failure is receiving digoxin (Lanoxin) and furosemide (Lasix). Which assessment finding requires immediate intervention?
- A. Heart rate of 60 beats per minute
- B. Apical pulse of 58 beats per minute
- C. Presence of a new murmur
- D. Blood pressure of 100/60 mmHg
Correct answer: C
Rationale: The correct answer is C. The presence of a new murmur in a client with heart failure receiving digoxin and furosemide is concerning as it may indicate valvular problems or other complications that require immediate intervention. A heart rate of 60 beats per minute and an apical pulse of 58 beats per minute are within normal limits for a client with heart failure on these medications. A blood pressure of 100/60 mmHg, while slightly low, may be expected due to the diuretic effect of furosemide and may not require immediate intervention unless the client is symptomatic.