HESI RN
HESI RN Exit Exam
1. 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?
- A. Has your son had any immunizations yet?
- B. Is your son sleepy and difficult to feed?
- C. Are you breastfeeding or bottle-feeding your son?
- D. Were any relatives born with birth defects?
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.
2. The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should be closely monitored?
- A. Serum potassium level
- B. Hemoglobin level
- C. White blood cell count
- D. Serum sodium level of 135 mEq/L
Correct answer: A
Rationale: The correct answer is A: Serum potassium level. In clients receiving erythropoietin therapy for chronic kidney disease, monitoring serum potassium levels is crucial due to the risk of developing hyperkalemia. Erythropoietin therapy can stimulate red blood cell production, leading to an increase in potassium levels. Monitoring potassium levels helps prevent complications associated with hyperkalemia, such as cardiac arrhythmias. Choices B, C, and D are incorrect because while hemoglobin levels are relevant for assessing the effectiveness of erythropoietin therapy, monitoring potassium levels is more critical due to the potential adverse effects of elevated potassium levels in CKD patients on this therapy.
3. A newly graduated female staff nurse requests reassignment to another client because a male client is asking her for a date and making suggestive comments. Which response is best for the nurse manager to provide?
- A. I have to call the supervisor to get someone else to transfer to this unit to care for him.
- B. I know you are a good nurse and can handle this client in a professional manner.
- C. I'll talk to the client about his behavior and insist that he stop it immediately.
- D. I'll change your assignment, but let's talk about how a nurse should respond to this kind of client.
Correct answer: D
Rationale: The best response for the nurse manager to provide in this situation is option D, which involves changing the assignment to address the nurse's immediate concern. It also offers an opportunity to have a conversation with the nurse about how to professionally handle such situations in the future. Option A is not the best response as it does not address the underlying issue and simply shifts the problem to another staff member. Option B, while supportive, does not actively address the client's inappropriate behavior. Option C is not ideal as the nurse manager should handle discussions about inappropriate behavior with clients themselves rather than delegating it to the staff nurse.
4. The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin shock. What is the most immediate intervention by the nurse?
- A. Dilute the dextrose in one liter of 0.9% Normal Saline solution.
- B. Mix the dextrose in a 50 ml piggyback for a total volume of 100 ml.
- C. Push the undiluted dextrose slowly through the current IV infusion.
- D. Ask the pharmacist to add the dextrose to a TPN solution.
Correct answer: C
Rationale: The correct immediate intervention by the nurse in this situation is to push the undiluted 50% dextrose slowly through the current IV infusion. This is because in cases of insulin shock, where the client has dangerously low blood sugar levels, administering 50% dextrose directly into the bloodstream helps rapidly increase blood glucose levels. Choice A is incorrect because diluting the dextrose in one liter of normal saline would delay the administration of glucose, which is needed urgently. Choice B is incorrect as mixing the dextrose in a piggyback solution would also delay the administration of the concentrated dextrose. Choice D is incorrect because adding dextrose to a TPN solution is not the immediate intervention needed to address the low blood sugar levels in a client experiencing insulin shock.
5. During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement?
- A. Notify the pediatrician immediately.
- B. Teach the parents about congenital heart defects.
- C. Document the finding in the infant's record.
- D. Apply oxygen via nasal cannula at 3 L/min.
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.
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