HESI RN
HESI 799 RN Exit Exam
1. Which assessment finding indicates to the nurse a client's readiness for pulmonary function tests?
- A. Expresses an understanding of the procedure.
- B. NPO for 6 hrs.
- C. No known drug allergies.
- D. Intravenous access intact.
Correct answer: A
Rationale: The correct answer is A: 'Expresses an understanding of the procedure.' This choice indicates that the client is mentally prepared for the pulmonary function tests, as understanding the procedure shows readiness and cooperation. Choices B, C, and D are incorrect. Choice B, 'NPO for 6 hrs,' pertains to fasting status and is not directly related to readiness for the test. Choice C, 'No known drug allergies,' is important information but does not specifically indicate readiness for pulmonary function tests. Choice D, 'Intravenous access intact,' is related to vascular access and not a direct indicator of readiness for the pulmonary function tests.
2. The best indicator that the client has learned how to give an insulin self-injection correctly is when the client can:
- A. Perform the procedure safely and correctly.
- B. Critique the nurse's performance of the procedure.
- C. Explain all steps of the procedure correctly.
- D. Correctly answer a post-test about the procedure.
Correct answer: A
Rationale: The best indicator of learning is the ability to perform the procedure safely and correctly, demonstrating skill acquisition. Choice A is correct because the client's ability to perform the insulin self-injection safely and correctly shows practical understanding and application of the skill. Choice B is incorrect because critiquing the nurse's performance does not necessarily demonstrate the client's ability to carry out the procedure themselves. Choice C is incorrect as merely explaining the steps verbally does not confirm the client's practical execution of the task. Choice D is also incorrect as answering a post-test does not directly assess the client's ability to physically perform the insulin self-injection.
3. The patient will begin taking penicillin G procaine (Wycillin). The nurse notes that the solution is milky in color. What action will the nurse take?
- A. Call the pharmacist and report the milky color.
- B. Add normal saline to dilute the medication.
- C. Call the physician and report the milky appearance.
- D. Administer the medication as ordered by the physician.
Correct answer: D
Rationale: The correct answer is to administer the medication as ordered by the physician. Penicillin G procaine (Wycillin) is known to have a milky appearance, which is normal. The milky color should not raise concerns for the nurse as it is an expected characteristic of this medication. Calling the pharmacist (choice A) or the physician (choice C) unnecessarily would delay the administration of the medication. Adding normal saline to dilute the medication (choice B) is not appropriate and could alter the medication's effectiveness. Therefore, the nurse should proceed with administering the medication as prescribed without any further action based on its milky appearance.
4. The nurse is assessing a client with rheumatoid arthritis who is taking a nonsteroidal anti-inflammatory drug (NSAID). Which laboratory value should the nurse monitor?
- A. Potassium
- B. Hemoglobin
- C. Serum creatinine
- D. White blood cell count
Correct answer: C
Rationale: When a client with rheumatoid arthritis is taking NSAIDs, the nurse should monitor serum creatinine levels. NSAIDs can potentially cause kidney damage, so monitoring creatinine levels helps assess for renal impairment. While monitoring hemoglobin, potassium, and white blood cell count may also be relevant in some cases, serum creatinine is the priority due to the risk of renal complications associated with NSAID use.
5. A client with diabetes mellitus reports feeling shaky and has a blood glucose level of 60 mg/dl. What action should the nurse take?
- A. Administer 15 grams of carbohydrate
- B. Administer a glucagon injection
- C. Provide a snack with protein
- D. Encourage the client to rest
Correct answer: A
Rationale: In the scenario described, the client is experiencing hypoglycemia with a blood glucose level of 60 mg/dl. The appropriate action for the nurse to take is to administer 15 grams of carbohydrate. Carbohydrate intake helps to rapidly raise blood sugar levels in cases of hypoglycemia. Administering a glucagon injection (Choice B) is not the initial treatment for mild hypoglycemia; it is typically used for severe hypoglycemia when the client is unable to consume oral carbohydrates. Providing a snack with protein (Choice C) is not the first-line intervention for hypoglycemia; immediate carbohydrate intake is necessary to raise blood sugar levels quickly. Encouraging the client to rest (Choice D) may be appropriate after administering the carbohydrate, but the priority is to address the low blood glucose levels by administering carbohydrates first.