HESI RN
HESI RN Exit Exam 2023 Questions
Question 1 of 5
A client with heart failure is prescribed furosemide (Lasix). Which assessment finding should the nurse report to the healthcare provider immediately?
Correct Answer: D
Rationale: The correct answer is D: Crackles in the lungs. Crackles indicate fluid overload in the lungs, a critical sign in a client with heart failure. This finding suggests that the furosemide may not be effectively managing the fluid balance, and immediate intervention is required.
Choices A, B, and C are not immediate concerns in this scenario. A heart rate of 60 beats per minute, a blood pressure of 100/60 mmHg, and the presence of a new murmur are findings that may require monitoring or intervention but are not as urgent as crackles in the lungs in a client with heart failure.
Question 2 of 5
A client with a postoperative wound that eviscerated yesterday has an elevated temperature. Which intervention is most important for the nurse to implement?
Correct Answer: B
Rationale: In this scenario, the most critical intervention is to obtain a wound swab for culture and sensitivity. This will help identify the causative organism present in the wound, enabling healthcare providers to prescribe the appropriate treatment. Initiating contact isolation (
Choice
A) may be necessary in certain situations but is not the priority in this case where infection is suspected. Assessing the temperature (
Choice
C) is important for monitoring the client's condition but does not address the underlying cause. Using alcohol-based solutions for hand hygiene (
Choice
D) is a standard practice for infection control but does not directly address the client's specific condition of a postoperative wound with evisceration and elevated temperature.
Question 3 of 5
The nurse is caring for a client with a history of myocardial infarction who is experiencing chest pain. Which intervention should the nurse implement first?
Correct Answer: A
Rationale: Administering oxygen therapy is the priority intervention in managing chest pain in a client with a history of myocardial infarction. Oxygen helps improve oxygenation to the heart muscle, which is crucial in reducing further damage. Obtaining an electrocardiogram (ECG) is important to assess for changes indicative of myocardial infarction, but providing oxygen takes precedence as it directly addresses the physiological need for oxygen. Administering nitroglycerin and aspirin are important interventions but are typically implemented after oxygen therapy to address vasodilation and antiplatelet effects, respectively.
Question 4 of 5
A client with newly diagnosed peptic ulcer disease is being taught about lifestyle modifications. Which client statement indicates that further teaching is needed?
Correct Answer: D
Rationale: The corrected question assesses the client's understanding of lifestyle modifications for peptic ulcer disease.
Choice D, 'I should avoid drinking alcohol to prevent irritation of my ulcer,' is the correct answer. This statement demonstrates that the client has a good grasp of the teaching provided, as alcohol can indeed irritate peptic ulcers.
Choices A, B, and C are all accurate statements that reflect appropriate understanding of managing peptic ulcer disease and do not indicate a need for further teaching.
Question 5 of 5
A client with diabetes mellitus is admitted with a blood glucose level of 600 mg/dl and is unresponsive. Which laboratory value is most concerning?
Correct Answer: C
Rationale: In a client with Hyperosmolar Hyperglycemic State (HHS), a serum pH of 7.30 is the most concerning value as it indicates acidosis, a life-threatening condition that requires immediate intervention.
Choices A, B, and D are not the most concerning in this scenario. A low serum potassium level (
Choice
A) may be expected due to cellular shift in hyperglycemia, a serum glucose level of 200 mg/dl (
Choice
B) is not as concerning compared to the extremely high initial glucose level, and a serum sodium level of 135 mEq/L (
Choice
D) is within the normal range and not the immediate priority.