2023/2024 HESI RN Exit Exam Version 4 (V4)- Questions & Answers with Rationales

HESI V-4 Rationales 1. The health care provider prescribes dopamine at 5 mcg/kg/minute for a client weighing 209 lbs. A 250 mL solution containing 0.8 mg/mL of dopamine is prepared by the pharmacy. At what rate in mL/hr should the nurse program the infusion pump to deliver the infusion? (Enter numeric value only. If rounding is required, round to the nearest whole number.) Correct answer: 36 Rationale: The nurse should first determine the client’s weight in kg by dividing 209 lbs/2.2 kg = 95 kg. Then the nurse should multiply the dose of 5 mcg x the client’s weight of 95 kg to determine the dose per minute, or 475 mcg. Then the nurse should multiply the dose per minute by 60 to determine the hourly dose amount or 475 mcg x 60 = 28500 mcg/hour. The solution available has 0.8 mg which can be converted to micrograms by multiplying by 1000 or 800 mcg/mL. To determine the rate of the infusion, the nurse should divide 28500 mcg/hour by 800 mcg/ml. This provides the amount of 35.625 mL/hour. When rounding to the nearest whole number the nurse would set the infusion pump to deliver 36 mL/hour. 2. A toddler bit through an electrical cord and received a burn to the mouth and tongue region. The client’s parents bring the child to the nearest emergency department. Which action should the nurse take at this time? You answered: C. Stabilize the client and prepare for transport to a hospital with a burn center. 3. The nurse is assigning morning care to unlicensed assistive personnel (UAP) to complete. Which client should the nurse delegate to UAP for morning care? Correct answer: D. Client with right-sided paralysis needing assistance completing a bath and dressing. Rationale: The client who has right-sided paralysis is the most appropriate to assign to UAP for morning care. Choices A and B are incorrect because the clients do not need UAP help. Choice C is incorrect because this client has an unstable respiratory status, has multiple intravenous access lines, and is lying on a pressure mattress. This client would best be cared for by the registered nurse. 4. A client with asthma is experiencing shortness of breath and has a peak flow meter reading in the yellow range. What does this finding indicate to the nurse? Correct answer: B. The client does not have good control and may need medications adjusted. Rationale: Peak flow meter numbers are placed into ranges or zones, which are used to evaluate the effectiveness of medication administration. The yellow range indicates that the client may be experiencing some difficulty and possible medication adjustment. Choice A is incorrect because the client has shortness of breath. Good control of asthma would be measured as being in the green range on the peak flow meter. Choice C is incorrect because the danger zone is measured as being in the red range on the peak flow meter. Choice D is incorrect because the peak flow meter does not evaluate the technique the client uses to administer medications through a meterdose inhaler. 5. The nurse is preparing a client for abdominal paracentesis for liver disease. Which actions will the nurse perform to prepare the client? (Select all that apply.) Correct answer: A. Weigh the client. B. Assess vital signs. C. Have the client void. D. Check if informed consent is obtained. Rationale: Prior to having an abdominal paracentesis the client needs to sign an informed consent since this is an invasive procedure. Other actions that the nurse needs to perform to prepare the client for the procedure include weighing the client, assessing the client’s vital signs, and having the client void. Choice E is incorrect because the client should be in the seated position with the feet supported. This position allows the fluid to collect in the lower abdomen to help with removal. The supine position will not aid in the removal of the fluid from the abdomen. 6. The emergency department of a mental health facility is admitting five adolescents from an outpatient residential care home who attempted a cluster suicide. What would be the best approach when admitting these clients? Correct answer: C. Admit them to different areas within the facility. Rationale: Cluster suicides are when a group of adolescents commit suicide within close proximity to each other. They most often occur in clients who are institutionalized. To prevent another attempt at cluster suicides the clients should be admitted to different areas within the facility. Choice A would encourage another attempt at cluster suicides. Choice B would depend upon each individual client’s mental status at the time of admission. Choice D would be inappropriate for the nurse to ask the clients to talk about why the suicide attempts failed. 7. The nurse is caring for a client who has a history of becoming constipated when taking opioid medication. What should the nurse instruct the client to do to avoid constipation when taking this type of pain medication? Correct answer: B. Eat fresh fruits and vegetables and increase activity. Rationale: Actions to help a client prevent constipation when taking opioid pain medication include increasing the intake of fiber, which can be accomplished by eating fresh fruits and vegetables, and by increasing activity. Choice A is incorrect because fluids are necessary to ensure adequate bowel functioning. Choice C is incorrect because rest and avoiding exercise before bedtime are not interventions to prevent constipation when taking opioid pain medication. Choice D is incorrect because the nurse cannot prescribe medications nor suggest substituting a prescribed pain medication with an over-the-counter preparation. 8. The nurse instructs a client with gastroesophageal reflux disease (GERD) on lifestyle modifications to help manage the disorder. Which client statement indicates that instruction has been effective? Correct answer: C. “I should eat smaller meals throughout the day.” Rationale: GERD can be managed with medication and lifestyle changes to include eating smaller meals throughout the day. Choice A is incorrect because acidic foods like tomatoes should be avoided. Choice B is incorrect because fatty foods delay gastric emptying. Choice D is incorrect because the client should elevate the head of the bed on 6 to 8 inch blocks to reduce heartburn and esophageal reflux. 9. Bed assignments are being made for four clients who are being admitted to a general medicalsurgical care area. Which client should be assigned a bed with a cardiac monitor? Correct answer: D. Client with a serum potassium level of 5.9 mEq/L. Rationale: An elevated potassium level or hyperkalemia alters the cell membrane of heart muscle. The most harmful consequences of an elevated potassium level are the effect on cardiac function. The client with an elevated serum potassium level should be placed in the bed with a cardiac monitor. Choices A, B, and C will not necessarily experience alterations in cardiac function based upon their admitting health problem. 10. The nurse is assessing a client in respiratory distress. Which assessment finding suggests the client has a tension pneumothorax? Correct answer: B. Deviated trachea. Rationale: In a tension pneumothorax the trachea is deviated toward the unaffected side as a result of the mediastinal shift. Choice A is incorrect because hemoptysis is not a manifestation of a tension pneumothorax. Choice C is incorrect because shortness of breath is a manifestation of all types of pneumothorax. Choice D is incorrect because these movements indicate a flail chest that is associated with fractured ribs. 11. The nurse in the newborn nursery assesses a neonate’s axillary temperature as being 97.7oF. Which action should the nurse take at this time? Correct answer: B. Document the temperature. Rationale: An axillary temperature of 97.7oF for a newborn is within normal limits (97.7 - 99.4oF). The nurse should document the temperature in the client’s chart. Choices A, C, and D are incorrect because this is a normal temperature. Clothing does not need to be removed and the baby does not need to be warmed with blankets or a warmer. 12. The nurse is preparing to administer otic medication to a 4 year old child. In which direction would the nurse apply pressure to the pinnae in order to straighten the client’s ear canal before instilling the medication? Correct answer: B. Direction B. Rationale: For a child older than 3 years of age, the pinnae should be pulled upward and backward to straighten the ear canal. Choice A is not used to help straighten the ear canal for any age of client. Choice C would be used to straighten the ear canal of a child less than 3 years of age. Choice D is not used to help straighten the ear canal for any age of client. 13. While assessing heart and lung sounds the nurse determines that a client has a pleural friction rub. What sound did the nurse hear during auscultation? Correct answer: D. Rationale: This is the sound of a pleural friction rub. Choice A is the sound of an early systolic murmur. Choice B is the sound of a mid-systolic click. Choice C is the sound of a wide split second heart sound. 14. A client is brought into the emergency department unresponsive. The family reports the client has been prescribed diazepam (Valium) for anxiety. What additional information does the nurse need to collect from the family to help determine the cause for the client’s health status? You answered: D. Evidence if the client ingested alcohol with the medication. 15. A client recovering from prophylactic bilateral mastectomies asks the nurse to explain breast reconstruction options. Which statement should the nurse include when providing the client with this information? Correct answer: C. “Breast massage should be done after reconstruction surgery to prevent fibrous capsule formation.” Rationale: To decrease the risk of fibrous capsule formation around a breast implant it is important for the client to perform breast massage as instructed. Choice A is incorrect because breast reconstruction can be done after a mastectomy or at a later time. Choice B is incorrect because breast implants have no nerve endings and will have no feelings or sensations. Choice D is incorrect because silicone implants have been associated with hardening and pain around the implant. 16. A client with septicemia is started on an infusion of dopamine hydrochloride. Which affect will the nurse assess that indicates the medication is effective? Correct answer: A. Urine output is increasing. Rationale: Dopamine hydrochloride improves circulation to the renal vascular bed and increases the renal glomerular filtration rate, which will cause an increase in urine output. This indicates that the medication has been effective. Choice B is incorrect because this medication increases the cardiac output. Choice C is incorrect because this medication has little or no effect on diastolic blood pressure. Choice D is incorrect because this medication causes an increase in systolic blood pressure. 17. While assessing the head and neck the nurse notes the following on a client’s right ear: How should the nurse document this finding? Correct answer: A. Tophi. Rationale: Tophi are raised areas of uric acid crystals that are seen in clients with gout. This finding should not be documented as being scar tissue, white heads, or calcium deposits. 18. The nurse assesses a client’s radial pulse as being 68 beats per minute but the apical heart rate is 90 beats per minute. What number should the nurse document as being this client’s pulse deficit? (Enter numeric value only.) Correct answer: 22 Rationale: When calculating the pulse deficit the nurse is to subtract the radial pulse rate from the apical pulse rate or 90 – 68 = 22. 19. A client is prescribed a medication to be given through an intramuscular injection. For which reason would the nurse use the Z-track technique when administering this medication? Correct answer: B. The medication is irritating to subcutaneous tissue. Rationale: The Z-track technique for an intramuscular injection has been found to decrease the leakage of irritating medications into the subcutaneous tissue. Choice A is incorrect because the Z-track technique can be used for any volume of intramuscular injection. Choice C is incorrect because the dorsogluteal site is seldom used for intramuscular injections because of the proximity to the sciatic nerve. Choice D is incorrect because intramuscular injections are to be administered with the needle at a 90 degree angle. 20. The nurse is preparing to administer medications through a client’s nasogastric tube. What will the nurse do first when administering these medications? Correct answer: C. Assess for placement of the nasogastric tube. Rationale: Before inserting any medications through the nasogastric tube the nurse needs to assess for correct placement of the tube. Choice A is incorrect because the stomach contents do not need to be aspirated from the stomach before administering the medication. Choice B is incorrect because tube placement should be checked before flushing the tube. Sterile water is not used to flush a nasogastric tube. Choice D is incorrect because the medications should not be provided until the nasogastric tube placement is checked. Sterile normal saline is not needed to flush a nasogastric tube. 21. A client is admitted for evaluation of painless purple lesions over the arms, legs, and face. Which laboratory test would be indicated first for this client?