HESI RN
RN HESI Exit Exam Questions
Question 1 of 5
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which assessment finding is most concerning to the nurse?
Correct Answer: C
Rationale: The correct answer is C: 'Use of accessory muscles.' In a client with a history of COPD, the use of accessory muscles indicates increased work of breathing and may signal respiratory failure, necessitating immediate intervention. This finding is concerning as it suggests the client is struggling to breathe adequately. Oxygen saturation of 90% (choice A) is low but may be expected in COPD patients; it requires monitoring and intervention but is not as immediately concerning as the use of accessory muscles. A respiratory rate of 24 breaths per minute (choice B) is within a normal range and, although slightly elevated, may be a typical response to pneumonia. Inspiratory crackles (choice D) can be a common finding in pneumonia and are not as indicative of impending respiratory failure as the use of accessory muscles.
Question 2 of 5
The nurse is caring for a client who is 2 days postoperative following abdominal surgery. The client reports pain at the incision site and a small amount of purulent drainage is noted. What is the most appropriate nursing action?
Correct Answer: D
Rationale: The correct answer is to notify the healthcare provider. Purulent drainage at the incision site is concerning as it may indicate an infection. The healthcare provider needs to be informed promptly to initiate appropriate treatment. Applying a sterile dressing (Choice A) may not address the underlying issue of infection. Reinforcing the dressing and documenting findings (Choice B) is important but should be preceded by notifying the healthcare provider. Removing the dressing and assessing the incision site (Choice C) may disturb the area and should be done under the guidance of the healthcare provider.
Question 3 of 5
A nurse is caring for a client with an indwelling urinary catheter. Which intervention is most important to include in the client's plan of care?
Correct Answer: A
Rationale: The correct answer is to ensure the catheter is always below the level of the bladder. Placing the catheter tubing above the level of the bladder can lead to backflow of urine, causing urinary tract infections. Changing the catheter bag every 48 hours is important but not as crucial as maintaining proper catheter positioning. Cleaning the perineal area daily and performing catheter care are essential tasks but do not directly address the prevention of complications associated with catheter placement.
Question 4 of 5
A client with cirrhosis is admitted with hepatic encephalopathy. Which laboratory value requires immediate intervention?
Correct Answer: D
Rationale: The correct answer is D. A prothrombin time of 18 seconds is most concerning in a client with hepatic encephalopathy as it indicates impaired liver function and an increased risk of bleeding. This requires immediate intervention to prevent bleeding complications. Choice A, serum ammonia level of 80 mcg/dl, is elevated but not as urgent as the abnormal prothrombin time. Choice B, bilirubin level of 3.0 mg/dl, is elevated but does not directly indicate an urgent need for intervention in this situation. Choice C, serum sodium level of 135 mEq/L, is within the normal range and does not require immediate intervention.
Question 5 of 5
The nurse is caring for a client with a history of atrial fibrillation who is prescribed warfarin (Coumadin). Which laboratory value should the nurse monitor closely?
Correct Answer: C
Rationale: The INR should be closely monitored in a client prescribed warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps determine if the client's blood is clotting appropriately. While prothrombin time (PT) is related to warfarin therapy, the INR is a more precise measure. Hemoglobin level and serum sodium level are not directly related to monitoring warfarin therapy.