HESI RN
HESI RN Exit Exam 2023
1. Which class of drugs is the only source of a cure for septic shock?
- A. Antihypertensives
- B. Anti-infectives
- C. Antihistamines
- D. Anticholesteremics
Correct answer: B
Rationale: The correct answer is B: Anti-infectives. Anti-infective agents, such as antibiotics, are essential in treating septic shock as they can eliminate bacteria and halt the progression of the condition by stopping the production of endotoxins. Antihypertensives (Choice A) are used to lower blood pressure, antihistamines (Choice C) are used to treat allergic reactions, and anticholesteremics (Choice D) are used to lower cholesterol levels. However, none of these drug classes directly address the bacterial infection that underlies septic shock.
2. A client with a history of coronary artery disease (CAD) is admitted with chest pain. Which diagnostic test should the nurse anticipate preparing the client for first?
- A. Electrocardiogram (ECG)
- B. Chest X-ray
- C. Arterial blood gases (ABGs)
- D. Echocardiogram
Correct answer: A
Rationale: The correct answer is A: Electrocardiogram (ECG). An electrocardiogram should be performed first to assess for cardiac ischemia in a client with a history of CAD and chest pain. An ECG provides immediate information about the heart's electrical activity, helping to identify signs of ischemia or a heart attack. While other diagnostic tests like chest X-ray, arterial blood gases, and echocardiogram may also be necessary in the evaluation of chest pain, they do not provide the initial direct assessment of cardiac ischemia that an ECG does.
3. Which nursing intervention is most important when caring for a client with myasthenia gravis?
- A. Encourage the client to rest frequently.
- B. Administer medication 30 minutes before meals.
- C. Maintain a patent airway.
- D. Monitor for signs of respiratory infection.
Correct answer: C
Rationale: Maintaining a patent airway is crucial for clients with myasthenia gravis because muscle weakness can affect the muscles responsible for breathing, potentially leading to respiratory compromise. Encouraging rest, administering medication, and monitoring for respiratory infections are important aspects of care but do not take precedence over ensuring a patent airway for adequate oxygenation.
4. In a client with cirrhosis admitted with ascites and jaundice, which clinical finding requires immediate intervention?
- A. Peripheral edema
- B. Confusion and altered mental status
- C. Increased abdominal girth
- D. Yellowing of the skin
Correct answer: B
Rationale: Confusion and altered mental status in a client with cirrhosis and associated ascites and jaundice are indicative of hepatic encephalopathy, a serious complication that requires immediate intervention. This condition can progress rapidly and lead to coma if not addressed promptly. Peripheral edema (choice A) and increased abdominal girth (choice C) are common manifestations of fluid retention in cirrhosis but may not require immediate intervention unless severe. Yellowing of the skin (choice D) is a classic sign of jaundice, which is already known in this client and may not necessitate immediate intervention unless associated with other concerning symptoms.
5. A client with cirrhosis is admitted with jaundice and ascites. Which intervention should the nurse implement first?
- A. Administer a diuretic as prescribed.
- B. Administer lactulose as prescribed.
- C. Monitor the client's weight daily.
- D. Assess the client's neurological status.
Correct answer: B
Rationale: Administering lactulose is the first priority in managing a client with cirrhosis to reduce ammonia levels and prevent worsening hepatic encephalopathy. Lactulose helps in decreasing the absorption of ammonia in the intestines and promotes its excretion through the stool. This intervention is crucial in preventing the development or progression of hepatic encephalopathy. Administering a diuretic (Choice A) may be necessary to manage ascites, but it is not the priority over lactulose in this scenario. Monitoring the client's weight (Choice C) is important to assess fluid retention but is not the first intervention required. Assessing the client's neurological status (Choice D) is essential in cirrhosis, but administering lactulose takes precedence to prevent hepatic encephalopathy.
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