HESI RN
RN HESI Exit Exam Questions
Question 1 of 5
The nurse enters a client's room and observes the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. What action should the nurse take first?
Correct Answer: A
Rationale: Correct Answer: The nurse should first place the side rails in an up position. This action is crucial to prevent the client from falling while the bed is being made. Choice B is incorrect as moving or turning the client is not necessary at this point. Choice C is not a priority when immediate safety concerns are present. Choice D, asking the client if they are comfortable, though important, should come after ensuring the client's safety by raising the side rails.
Question 2 of 5
A male client is having abdominal pain after a left femoral angioplasty and stent, and is asking for additional pain medication for right lower quadrant pain (9/10). Two hours ago, he received hydrocodone/acetaminophen 7.5/325 mg. His vital signs are elevated from previous readings: temperature 97.8°F, heart rate 102 beats/minute, respiration 20 breaths/minute. His abdomen is swollen, the groin access site is tender, peripheral pulses are present, but the left is greater than the right. What data is needed to make this report complete?
Correct Answer: B
Rationale: The correct answer is B. In this scenario, the client is experiencing abdominal pain after a left femoral angioplasty and stent, with signs of potential complications such as a swollen abdomen, tenderness at the groin access site, and unequal peripheral pulses. The client's vital signs are also elevated, indicating a worsening condition. Given these findings, the immediate evaluation by the surgeon is crucial to assess for serious complications like internal bleeding or ischemia. Choice A is incorrect as the focus should be on the urgent need for surgical evaluation rather than lung sounds and oxygen saturation. Choice C is irrelevant to the immediate management of the client's current situation. Choice D, while providing background information, is not essential for the urgent intervention required in this case.
Question 3 of 5
An adult female client with chronic kidney disease (CKD) asks the nurse if she can continue taking over-the-counter medications. Which medication provides the greatest threat to this client?
Correct Answer: A
Rationale: The correct answer is A: Magnesium hydroxide (Maalox). In clients with CKD, magnesium can accumulate to toxic levels due to decreased excretion by the kidneys. Therefore, it poses the greatest threat to this client population. Choice B, birth control pills, is not typically contraindicated in CKD. Choice C, cough syrup containing codeine, may require dose adjustments but is not the greatest threat. Choice D, cold medication containing alcohol, is a concern mainly in liver disease, not CKD.
Question 4 of 5
The nurse is caring for a client following a myelogram. Which assessment finding should the nurse report to the healthcare provider immediately?
Correct Answer: A
Rationale: The correct answer is A: Complaint of headaches and stiff neck. Headaches and stiff neck following a myelogram may indicate a cerebrospinal fluid (CSF) leak or other complications that require prompt medical attention. Reporting this finding immediately is crucial to prevent further complications. Choices B, C, and D are incorrect because while they may warrant monitoring and intervention, they are not as indicative of a potentially serious complication as the symptoms described in choice A.
Question 5 of 5
A woman who takes pyridostigmine for myasthenia gravis (MG) arrives at the emergency department complaining of extreme muscle weakness. Her adult daughter tells the nurse that since yesterday her mother has been unable to smile. Which assessment finding warrants immediate intervention by the nurse?
Correct Answer: A
Rationale: Uncontrollable drooling can be a sign of a myasthenic crisis, which requires immediate medical intervention to prevent respiratory failure. Drooling indicates difficulty in swallowing, which can lead to aspiration and respiratory compromise. Inability to raise voice (choice B) and tingling of extremities (choice C) are not typically associated with myasthenic crisis. Although eyelid drooping (choice D) is a common symptom of myasthenia gravis, it is not as urgent as uncontrollable drooling in indicating a potential crisis.