Questions 9

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HESI RN Exit Exam Questions

Question 1 of 5

During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement?

Correct Answer: C

Rationale: The correct intervention when a nurse finds an irregular heart rate in a newborn is to document the finding in the infant's record. An irregular heart rate is a common occurrence in newborns and does not necessarily require immediate medical intervention. Notifying the pediatrician immediately is unnecessary unless there are other concerning symptoms. Teaching the parents about congenital heart defects is not the priority in this situation. Applying oxygen via nasal cannula at 3 L/min is not indicated for an irregular heart rate without further assessment or medical indication.

Question 2 of 5

The nurse determines that a client's pupils constrict as they change focus from a far object. What documentation should the nurse enter about this finding?

Correct Answer: A

Rationale: The correct answer is A: 'Pupils reactive to accommodation.' When pupils constrict as the client changes focus from a far object to a near one, it indicates a normal response known as accommodation. This physiological process allows the eyes to adjust their focus, and it is a healthy finding. Choice B is incorrect because nystagmus is an involuntary eye movement, not related to the change in focus. Choice C is irrelevant to the scenario and does not describe the observed finding. Choice D refers to pupillary constriction in response to light, not accommodation to changes in focus.

Question 3 of 5

The nurse who is working on a surgical unit receives a change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?

Correct Answer: D

Rationale: The correct answer is D. A client who had an abdominal-perineal resection 2 days ago with no drainage on the dressing but is presenting with fever and chills requires immediate attention. This presentation raises concerns for peritonitis, a serious complication that necessitates prompt assessment and intervention to prevent further complications. Choices A, B, and C do not indicate an immediate risk for a life-threatening condition like peritonitis, making them lower priority compared to choice D.

Question 4 of 5

Before a dressing change to his legs, which intervention is most important for the nurse to implement?

Correct Answer: C

Rationale: Maintaining strict aseptic technique is crucial before a dressing change for burn patients to prevent infection. Encouraging the patient to stay at the bedside, using distraction techniques, or placing a drape over the burn area are not as critical as ensuring asepsis in this situation.

Question 5 of 5

A client with hypertension receives a prescription for enalapril, an angiotensin-converting enzyme inhibitor. What instruction should the nurse include in the medication teaching plan?

Correct Answer: B

Rationale: The correct answer is B: 'Report increased bruising or bleeding.' Enalapril, an ACE inhibitor, can lead to thrombocytopenia, a condition characterized by a low platelet count, which increases the risk of bruising and bleeding. Instructing the client to report any signs of increased bruising or bleeding is crucial for monitoring and managing this potential side effect. Choices A, C, and D are incorrect: A - Increasing potassium-rich foods is not directly related to the side effects of enalapril. C - Developing a cough is a common side effect of ACE inhibitors, but it does not warrant stopping the medication unless advised by a healthcare provider. D - Limiting intake of leafy green vegetables is not necessary with enalapril unless specifically instructed by a healthcare provider for individual reasons.

Similar Questions

A client with hypertension receives a prescription for enalapril, an angiotensin-converting enzyme inhibitor. What instruction should the nurse include in the medication teaching plan?
During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement?
What is the most important instruction for the nurse to provide a client being discharged following treatment for Guillain-Barre syndrome?
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first?
A client with a history of chronic heart failure is admitted with shortness of breath. Which assessment finding is most concerning?

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