HESI RN
RN HESI Exit Exam
1. A client with pneumonia has arterial blood gases levels at: pH 7.33; PaCO2 49 mm/Hg; HCO3 25 mEq/L; PaO2 95. What intervention should the nurse implement based on these results?
- A. Institute coughing and deep breathing protocols.
- B. Administer oxygen via nasal cannula.
- C. Prepare for intubation and mechanical ventilation.
- D. Increase IV fluids to improve hydration.
Correct answer: A
Rationale: The ABG results indicate respiratory acidosis due to an elevated PaCO2 (49 mm/Hg), indicating hypoventilation. The appropriate intervention for respiratory acidosis is to improve ventilation. Coughing and deep breathing protocols can help the client to effectively ventilate and improve gas exchange. Administering oxygen via nasal cannula (Choice B) may be necessary in respiratory distress situations, but addressing the underlying cause of hypoventilation is crucial. Intubation and mechanical ventilation (Choice C) are not the first-line interventions for uncomplicated respiratory acidosis. Increasing IV fluids (Choice D) does not directly address the respiratory acidosis present in this scenario.
2. When preparing to insert a nasogastric (NG) tube for a client admitted to the surgical unit with symptoms of a possible intestinal obstruction, which intervention should the nurse implement?
- A. Elevate the head of the bed 60 to 90 degrees
- B. Administer an antiemetic
- C. Prepare the client for surgery
- D. Provide oral care
Correct answer: A
Rationale: Elevating the head of the bed to 60 to 90 degrees is essential when inserting an NG tube. This position helps facilitate the passage of the tube through the esophagus into the stomach and reduces the risk of aspiration. Administering an antiemetic may be necessary to control nausea or vomiting, but it is not the primary intervention when inserting an NG tube. Preparing the client for surgery is not indicated solely for the insertion of an NG tube. Providing oral care is important for maintaining oral hygiene but is not directly related to inserting an NG tube.
3. An adult male who lives alone is brought to the Emergency Department by his daughter who found him unresponsive. Initial assessment indicated that the client has minimal respiratory effort, and his pupils are fixed and dilated. At the daughter's request, the client is intubated and ventilated. Which nursing intervention has the highest priority?
- A. Notify the client's minister of his condition.
- B. Determine if the client has an executed living will.
- C. Provide the family with information about palliative care.
- D. Discuss the possibility of organ donation with the family.
Correct answer: B
Rationale: Verifying whether the client has an executed living will is crucial to ensuring that his treatment preferences are followed. In this critical situation, knowing the client's wishes regarding medical interventions is paramount. Options A, C, and D are not the highest priority as they do not directly address the immediate need to determine the client's treatment preferences.
4. A client who had a gestational trophoblastic disease (GTD) evacuated 2 days ago is being... What intervention is most important for the nurse to implement?
- A. Teach the client about the use of a home pregnancy test.
- B. Schedule weekly home visits to draw hCG values.
- C. Schedule a 5-week follow-up with the healthcare provider.
- D. Begin chemotherapy administration during the first home visit.
Correct answer: B
Rationale: The most important intervention for the nurse to implement is to schedule weekly home visits to draw hCG values. Monitoring hCG levels is crucial in detecting potential complications like choriocarcinoma following GTD evacuation. Teaching about home pregnancy tests (Choice A) may not be as immediate and critical as monitoring hCG levels. A 5-week follow-up appointment (Choice C) may be too delayed for close monitoring. Initiating chemotherapy (Choice D) without appropriate hCG monitoring and evaluation is not recommended as the first-line intervention.
5. A client with cirrhosis is admitted with jaundice and ascites. Which laboratory value requires immediate intervention?
- A. Serum albumin of 3.0 g/dL
- B. Serum bilirubin of 3.0 mg/dL
- C. Serum ammonia level of 80 mcg/dL
- D. Serum sodium level of 135 mEq/L
Correct answer: C
Rationale: A serum ammonia level of 80 mcg/dL is most concerning in a client with cirrhosis as it may indicate hepatic encephalopathy, requiring immediate intervention. High serum ammonia levels can lead to altered mental status, confusion, and even coma. Serum albumin (choice A) is often decreased in cirrhosis but does not require immediate intervention. Serum bilirubin (choice B) elevation is expected in cirrhosis and may not require immediate intervention unless very high. Serum sodium (choice D) within the given range is generally acceptable and does not require immediate intervention.
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