HESI RN
HESI RN Exit Exam Questions
Question 1 of 5
A client with a history of alcoholism is admitted with confusion, ataxia, and nystagmus. Which nursing intervention is a priority for this client?
Correct Answer: B
Rationale: The correct answer is B: Administer thiamine as prescribed. Administering thiamine is crucial in clients with a history of alcoholism to prevent Wernicke's encephalopathy, which is characterized by confusion, ataxia, and nystagmus. Monitoring for signs of alcohol withdrawal (choice
A) is important but not the priority. Providing a quiet environment (choice
C) and initiating fall precautions (choice
D) are important interventions, but administering thiamine takes precedence due to the risk of Wernicke's encephalopathy.
Question 2 of 5
A client is admitted for cellulitis surrounding an insect bite on the lower right arm, and intravenous (IV) antibiotic therapy is prescribed. Which action should the nurse implement before performing venipuncture?
Correct Answer: A
Rationale: Before performing venipuncture for IV therapy, the nurse should lower the right arm below the level of the heart. Lowering the arm helps dilate the veins, making it easier to locate and access a suitable vein for the procedure. Elevating the arm on a pillow, applying a tourniquet above the insertion site, or applying a warm compress to the insertion site are not appropriate actions before venipuncture as they can affect the venous blood flow and make the procedure more challenging.
Question 3 of 5
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which intervention should the nurse implement first?
Correct Answer: C
Rationale: Assessing the client's oxygen saturation is crucial in a client with COPD receiving supplemental oxygen to ensure adequate oxygenation. This assessment helps determine if the current oxygen therapy is effective or if adjustments are necessary. While administering a bronchodilator is important in managing COPD, assessing oxygen saturation takes precedence to address the client's immediate oxygen needs. Assessing the respiratory rate is also important but evaluating oxygen saturation provides more direct information about the client's oxygen status. Elevating the head of the bed can improve ventilation but is not the priority when assessing oxygen saturation in a client with COPD receiving supplemental oxygen.
Question 4 of 5
The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based gel hand cleaner before performing catheter care. The UAP rubs both hands thoroughly for 2 minutes while standing at the bedside. What action should the nurse take?
Correct Answer: B
Rationale: The correct answer is B. Alcohol-based hand rubs are effective with a shorter rub time, typically around 20-30 seconds. Standing at the bedside for 2 minutes to rub hands thoroughly is unnecessary and can lead to wastage of resources. It's essential for the nurse to educate the UAP on proper hand hygiene techniques to ensure efficient and effective infection control practices.
Choices A, C, and D are incorrect because encouraging the UAP to remain in the client's room, discussing handwashing instead of hand rubs, and questioning glove use are not the most appropriate actions in this scenario.
Question 5 of 5
In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?
Correct Answer: A
Rationale: The correct answer is A: Watery diarrhea. This finding is the most important to report as it may indicate Clostridioides difficile infection, a severe side effect of antibiotic therapy. Clostridioides difficile infection can lead to serious complications and requires immediate medical attention.
Choices B, C, and D are common side effects of linezolid but are not as critical as watery diarrhea in this context.