HESI RN
RN HESI Exit Exam Questions
Question 1 of 5
A client with cirrhosis is admitted with jaundice and ascites. Which laboratory value requires immediate intervention?
Correct Answer: C
Rationale: A serum ammonia level of 80 mcg/dL is most concerning in a client with cirrhosis as it may indicate hepatic encephalopathy, requiring immediate intervention. High serum ammonia levels can lead to altered mental status, confusion, and even coma. Serum albumin (choice
A) is often decreased in cirrhosis but does not require immediate intervention. Serum bilirubin (choice
B) elevation is expected in cirrhosis and may not require immediate intervention unless very high. Serum sodium (choice
D) within the given range is generally acceptable and does not require immediate intervention.
Question 2 of 5
A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which intervention should the nurse implement first?
Correct Answer: D
Rationale: The correct answer is to administer 50% dextrose IV push first. In hyperglycemic hyperosmolar syndrome, the main goal is to rapidly reduce blood glucose levels to prevent further complications. Administering dextrose intravenously can help reverse the effects of high blood glucose levels quickly. Administering intravenous fluids, monitoring urine output, and obtaining a blood glucose level are important interventions but are not the first priority in treating HHS. Administering 50% dextrose IV push takes precedence as it directly addresses the elevated blood glucose levels.
Question 3 of 5
A female client reports that she drank a liter of a solution to cleanse her intestines but vomited immediately after. How many ml of fluid intake should the nurse document?
Correct Answer: C
Rationale: The correct answer is 760 ml. One liter equals 1000 ml. As the client vomited immediately after drinking, she would have expelled approximately 240 ml (1 cup). Subtracting this from the initial intake of 1000 ml gives us 760 ml as the remaining fluid intake that should be documented.
Choices A, B, and D are incorrect because they do not reflect the correct calculation of subtracting the amount vomited from the initial intake.
Question 4 of 5
A client who is post-op day 1 after abdominal surgery reports pain at the incision site. The nurse notes the presence of a small amount of serosanguineous drainage. What is the most appropriate nursing action?
Correct Answer: B
Rationale: The correct answer is to reinforce the dressing and document the findings. It is important to monitor the incision site closely after surgery, especially when there is a small amount of serosanguineous drainage. Reinforcing the dressing helps maintain cleanliness and pressure on the wound. Documenting the findings is crucial for tracking the client's progress and alerting healthcare providers if necessary. Applying a sterile dressing (
Choice
A) may not be needed if the current dressing is intact. Removing the dressing (
Choice
C) can increase the risk of contamination. Notifying the healthcare provider (
Choice
D) is not the first step for minor drainage on post-op day 1.
Question 5 of 5
An 80-year-old male client with multiple chronic health problems becomes disoriented, agitated, and combative 24 hours after being admitted to the hospital. What nursing intervention is most important to include in this client's plan of care?
Correct Answer: B
Rationale: Reorienting the client frequently is the most important nursing intervention in this scenario. It helps reduce confusion and agitation, which are common symptoms of acute delirium in hospitalized elderly clients. Requesting a psychiatric consult (choice
A) may be necessary if the reorientation does not improve the client's condition or if there are underlying psychiatric concerns, but reorientation should be attempted first. Administering antipsychotic medications (choice
C) should not be the initial intervention as they can have adverse effects in elderly individuals. Obtaining a sitter (choice
D) may provide support but does not directly address the client's disorientation and agitation.