HESI RN
HESI Leadership Questions
Extract:
Question 1 of 5
Which client requires the most immediate intervention by the nurse?
Correct Answer: B
Rationale: The client with acute kidney injury and unresponsiveness likely has uremic encephalopathy, a life-threatening condition requiring immediate intervention. The other clients' conditions are less urgent as they are receiving appropriate treatments.
Question 2 of 5
An adult woman who had gastric bypass surgery two weeks ago is admitted because she is exhibiting signs of anastomosis leakage. Her vital signs are: temperature 100°F (37.8°C), blood pressure 98/50 mm Hg, heart rate 135 beats/minute, and respiratory rate 24 breaths/minute. Which intervention is most important for the nurse to include in this client's plan of care?
Correct Answer: A
Rationale: IV fluid replacement addresses hypovolemia and prevents shock, critical given the client's vital signs. Recording drainage, assessing skin, and turning are important but secondary to stabilizing fluid status.
Question 3 of 5
A male client is admitted with difficulty breathing related to a recent diagnosis of metastatic lung cancer. He tells the nurse that he does not want to be hooked up to any machines. His vital signs are heart rate 120 beats/minute, blood pressure 98/50 mm Hg, respirations 30 breaths/minute, and oxygen saturation 88%. Which action should the nurse take?
Correct Answer: D
Rationale: Consulting palliative care respects the client's wish to avoid machines and provides holistic end-of-life support. Power of attorney, analgesics, and IV discontinuation are secondary or inappropriate.
Question 4 of 5
The charge nurse of a critical care unit must transfer a client to a general unit to make a bed available for an incoming trauma client. Based on the information provided, which client is best for the nurse to recommend for transfer to the general unit?
Correct Answer: D
Rationale: The client with nephrotic syndrome is relatively stable, requiring routine care suitable for a general unit. The other clients have acute, unstable conditions requiring critical care monitoring.
Question 5 of 5
An adult woman with metastatic pancreatic cancer has requested that no heroic measures are implemented to save her life. Instructions from the healthcare provider have been received to transfer the client to a palliative care room. Which action is most important for the nurse to take first?
Correct Answer: B
Rationale: Giving a detailed report ensures continuity of care, critical for the client's palliative needs. Transferring chart codes, escorting family, or providing written information are secondary to effective handoff.