HESI RN
HESI 799 RN Exit Exam
1. Which nursing intervention has the highest priority for a multigravida who delivered an hour ago?
- A. Maintain cold packs to the perineum for 24 hours.
- B. Assess the client's pain level frequently.
- C. Observe for appropriate interaction with the infant.
- D. Assess fundal tone and lochia flow.
Correct answer: D
Rationale: Assessing fundal tone and lochia flow is crucial in the immediate postpartum period to detect postpartum hemorrhage, a life-threatening complication. Monitoring these parameters allows for early identification of excessive bleeding, enabling prompt intervention. While maintaining cold packs to the perineum, assessing pain levels, and observing for appropriate interaction with the infant are important aspects of postpartum care, assessing fundal tone and lochia flow takes precedence due to its direct relevance to identifying and managing a potential emergency situation.
2. A client with an eating disorder is being treated in a behavioral health unit. Which behavior would the nurse expect to see if the client is responding positively to the treatment?
- A. Adherence to the treatment plan and increased self-care activities.
- B. Increased isolation from others.
- C. Frequent complaining about treatment procedures.
- D. Refusal to eat meals provided by the unit.
Correct answer: A
Rationale: A positive response to treatment for a client with an eating disorder is indicated by adherence to the treatment plan and an increase in self-care activities. These behaviors show that the client is actively engaging in their treatment and taking steps towards recovery. Option B, increased isolation from others, is not indicative of a positive response to treatment as it may suggest withdrawal or avoidance. Option C, frequent complaining about treatment procedures, is not a behavior that signifies a positive response; it may indicate dissatisfaction or discomfort with the treatment. Option D, refusal to eat meals provided by the unit, is also not a positive response as it could suggest continued resistance to treatment and potential worsening of symptoms.
3. The nurse is caring for a patient who has had severe vomiting. The patient’s serum sodium level is 130 mEq/L. The nurse will expect the patient’s provider to order which treatment?
- A. Diuretic therapy
- B. Intravenous hypertonic 5% saline
- C. Intravenous normal saline 0.9%
- D. Oral sodium supplements
Correct answer: C
Rationale: In this scenario, the patient has hyponatremia with a serum sodium level of 130 mEq/L. For a serum sodium level between 125 and 135 mEq/L, the appropriate treatment is intravenous normal saline 0.9%. Normal saline helps to increase the sodium content in the vascular fluid. Diuretic therapy would exacerbate sodium and fluid depletion, which is not suitable for a patient already dehydrated from severe vomiting. Intravenous hypertonic 5% saline is typically reserved for severe hyponatremia with a serum sodium level below 120 mEq/L. Oral sodium supplements are not feasible in this case as the patient is vomiting and may not be able to tolerate oral intake easily.
4. What must first occur before a cell can be divided to grow, develop, and reproduce organisms?
- A. RNA replication
- B. DNA replication
- C. Gene replication
- D. Chromosome replication
Correct answer: B
Rationale: The correct answer is B: DNA replication. Before a cell can divide to grow, develop, and reproduce organisms, DNA replication must occur. This process ensures that each daughter cell receives an identical set of genetic information. Choices A, C, and D are incorrect because while RNA, genes, and chromosomes are essential components of cell division, DNA replication is the specific process that must first occur to ensure accurate transmission of genetic material.
5. The nurse is providing discharge instructions to a client who has had a stroke. Which intervention should the nurse recommend to prevent aspiration during meals?
- A. Encourage the client to take large bites of food
- B. Advise the client to eat quickly to prevent fatigue
- C. Offer the client thin liquids with meals
- D. Instruct the client to sit upright while eating
Correct answer: D
Rationale: Instructing the client to sit upright while eating is crucial to prevent aspiration in stroke clients. This position helps in safe swallowing and reduces the risk of food or liquid entering the airway. Encouraging the client to take large bites of food (Choice A) can increase the risk of choking and aspiration. Advising the client to eat quickly (Choice B) may lead to fatigue and compromise safe swallowing. Offering thin liquids (Choice C) can also increase the risk of aspiration in stroke clients, as thicker liquids are usually recommended to prevent aspiration.