HESI RN
HESI Leadership Questions
Extract:
Question 1 of 5
The nurse receives a change-of-shift report from the prior nurse assigned to a group of clients on a post-surgical unit. Which client requires the most immediate intervention by the nurse?
Correct Answer: A
Rationale: The client with no drainage and chills may have an infection or sepsis, which are life-threatening complications requiring immediate assessment and physician notification. The chest tube drainage is normal, the gunshot wound drainage is not excessive, and the mastectomy drain output is expected, making these less urgent.
Question 2 of 5
When triaging emergency room clients, which client should the nurse assess first?
Correct Answer: B
Rationale: Severe right lower abdominal pain with fever and vomiting suggests appendicitis, a surgical emergency requiring immediate assessment. Vomiting, leg pain, and green sputum are less urgent conditions.
Question 3 of 5
The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the PN?
Correct Answer: B
Rationale: Validating IV flow rates is within the PN's scope, involving routine checks of orders and drip rates. Initial wound care, assessing catheter need, and postoperative assessments require RN clinical judgment.
Question 4 of 5
Four clients are scheduled to receive IV infusions, but there are only three intravenous (IV) pumps available. Which prescribed infusion can most safely be administered without an IV infusion pump?
Correct Answer: A
Rationale: Ceftriaxone can be safely administered by gravity infusion with nurse monitoring, as its dosing is less sensitive to minor flow rate variations. Heparin, magnesium, and insulin require precise infusion rates due to risks of bleeding, toxicity, or glucose imbalances, necessitating an IV pump.
Question 5 of 5
A postoperative client's respiratory rate decreased from 14 breaths/minute to 6 breaths/minute after administration of an opioid analgesic. Thirty minutes later, the client's respiratory rate decreases to 4 breaths/minute, and the nurse caring for the client notifies the healthcare provider and administers a dose of intravenous (IV) naloxone. The charge nurse should counsel the nurse regarding which intervention?
Correct Answer: B
Rationale: The nurse should have notified the provider at a respiratory rate of 6 breaths/minute, as this indicates opioid-induced respiratory depression. Delaying until 4 breaths/minute risked client safety. Other interventions were appropriate.