HESI RN
HESI RN Exit Exam Questions
Question 1 of 5
The mother of a one-month-old boy born at home brings the infant to his first well-baby visit. She mentions that he was born two weeks after his due date and is a 'good, quiet baby' who almost never cries. To assess for hypothyroidism, what question is most important for the nurse to ask the mother?
Correct Answer: B
Rationale: The correct answer is B. Sleepiness and difficulty feeding are key signs of congenital hypothyroidism, which requires early diagnosis and treatment. Asking about immunizations (choice A) is important but not directly related to assessing hypothyroidism. The feeding method (choice C) is relevant for overall health but not specific to hypothyroidism. Inquiring about relatives with birth defects (choice D) is not the most crucial question to assess hypothyroidism in this scenario.
Question 2 of 5
In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, the nurse assesses that the client is lethargic with a blood pressure of 90/60 mm Hg, a pulse rate of 118 beats per minute, and a respiratory rate of 8 breaths per minute. What assessment should the nurse perform next?
Correct Answer: D
Rationale: In this scenario, the client is presenting with signs of potential opioid overdose, such as lethargy, hypotension, tachycardia, and bradypnea. The next assessment the nurse should perform is to observe the amount and dose of morphine in the PCA pump syringe. This evaluation is crucial in determining if the client is receiving an excessive amount of morphine, leading to the observed symptoms. Checking the PCA pump syringe will provide essential information to address the client's condition promptly and prevent further complications. Choices A, B, and C are not the priority in this situation as they do not directly address the potential cause of the client's symptoms related to morphine administration.
Question 3 of 5
An adolescent's mother calls the clinic because the teen is having recurrent vomiting and has been combative in the last 2 days. The mother states that the teen takes vitamins, calcium, and magnesium supplements along with aspirin. Which nursing intervention has the highest priority?
Correct Answer: B
Rationale: In this scenario, the highest priority nursing intervention is to instruct the mother to take the teen to the emergency room. The symptoms of recurrent vomiting, combative behavior, and the medications (vitamins, calcium, magnesium supplements, and aspirin) taken by the teen suggest a possible overdose or serious adverse reaction. Therefore, immediate medical evaluation is crucial to assess and manage any potential toxicity or adverse effects. Advising to withhold all medications by mouth (Choice A) may delay necessary treatment. Recommending withholding food and fluids for 2 hours (Choice C) may not address the underlying cause of the symptoms. Suggesting slow and deep breathing (Choice D) is not appropriate in this urgent situation requiring immediate medical attention.
Question 4 of 5
The mother of a one-month-old boy born at home brings the infant to his first well-baby visit. The infant was born two weeks after his due date and is described as a 'good, quiet baby' who almost never cries. To assess for hypothyroidism, what question is most important for the nurse to ask the mother?
Correct Answer: B
Rationale: The correct answer is B. Excessive sleepiness and difficulty feeding can be signs of hypothyroidism in infants. Asking about the infant's sleepiness and feeding pattern is crucial in assessing for hypothyroidism. Choice A is incorrect because immunizations are not directly related to hypothyroidism. Choice C is about feeding method and not specific to hypothyroidism. Choice D is unrelated as it asks about relatives with birth defects, which does not directly assess the infant's condition.
Question 5 of 5
The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede Method. When performing a return demonstration, the client applies pressure to the umbilical areas of his abdomen. What instruction should the nurse provide?
Correct Answer: D
Rationale: The client is applying pressure in the wrong region (umbilical area) and should be instructed to apply pressure at the suprapubic area. Applying downward manual pressure at the suprapubic region helps in emptying the bladder effectively by assisting in pushing the urine out through the urethra. Choices A, B, and C are incorrect because they do not address the specific issue of applying pressure to help empty the bladder using the Crede Method.