HESI RN EXIT EXAM COMPLETE QUESTIONS WITH 100% VERIFIED ANSWERS AND DETAILED RATIONALES

HESI RN EXIT EXAM COMPLETE QUESTIONS WITH 100% VERIFIED ANSWERS AND DETAILED RATIONALES 1. A nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which finding indicates the need for immediate intervention? A) Barrel-shaped chest B) Clubbing of fingers C) Oxygen saturation of 88% D) Productive cough with green sputum Answer: C) Oxygen saturation of 88% Rationale: An oxygen saturation below 90% indicates hypoxemia and requires immediate intervention. While barrel-shaped chest, clubbing, and productive cough are common findings in COPD, they do not indicate immediate life-threatening compromise like severe hypoxemia does. ________________________________________ 2. A postpartum client reports sudden, sharp chest pain and shortness of breath. The nurse notes tachycardia and hypotension. What condition should the nurse suspect first? A) Pulmonary embolism B) Mastitis C) Uterine atony D) Postpartum hemorrhage Answer: A) Pulmonary embolism Rationale: Sudden chest pain, shortness of breath, tachycardia, and hypotension in a postpartum client are classic signs of pulmonary embolism, a life-threatening complication that requires immediate intervention. Risk factors include immobility, cesarean delivery, and hypercoagulable state of pregnancy. ________________________________________ 3. A client with schizophrenia is experiencing auditory hallucinations. Which nursing intervention is most appropriate initially? A) Tell the client the voices are not real B) Ask the client what the voices are saying C) Ignore the hallucinations to avoid reinforcing them D) Administer PRN antipsychotic medication immediately Answer: B) Ask the client what the voices are saying Rationale: The initial intervention is to assess the content of the hallucinations to determine if the client is at risk for harm to self or others. This provides safety information and demonstrates therapeutic communication. Telling the client the voices are not real denies their experience and can damage the therapeutic relationship. ________________________________________ 4. A nurse is preparing to administer digoxin to a client with heart failure. Which assessment finding should cause the nurse to hold the medication? A) Heart rate of 68 beats per minute B) Serum potassium level of 3.2 mEq/L C) Blood pressure of 120/78 mmHg D) Respiratory rate of 18 breaths per minute Answer: B) Serum potassium level of 3.2 mEq/L Rationale: Hypokalemia (potassium 3.5 mEq/L) increases the risk of digoxin toxicity. The nurse should hold the medication and notify the healthcare provider. Normal heart rate (68), blood pressure, and respiratory rate do not contraindicate digoxin administration. ________________________________________ 5. A 2-year-old child is admitted with dehydration. Which assessment finding indicates severe dehydration? A) Sunken fontanel B) Dry mucous membranes C) Capillary refill of 2 seconds D) Urine output of 30 mL/hour Answer: A) Sunken fontanel Rationale: A sunken fontanel in a 2-year-old indicates severe dehydration and requires immediate intervention. Capillary refill of 2 seconds is normal, and urine output of 30 mL/hour is adequate. Dry mucous membranes indicate mild to moderate dehydration. ________________________________________ 6. A client with diabetes mellitus type 1 is exhibiting signs of diabetic ketoacidosis (DKA). Which laboratory value is consistent with this diagnosis? A) Serum pH of 7.35 B) Serum bicarbonate of 22 mEq/L C) Blood glucose of 550 mg/dL D) Serum potassium of 5.0 mEq/L Answer: C) Blood glucose of 550 mg/dL Rationale: DKA is characterized by blood glucose levels typically above 250 mg/dL. A glucose of 550 mg/dL is consistent with DKA. DKA also presents with metabolic acidosis (pH 7.3) and low bicarbonate (15 mEq/L). Serum potassium may be normal or elevated initially despite total body depletion. ________________________________________ 7. A nurse is teaching a client about self-administration of subcutaneous heparin. Which statement indicates the client understands the teaching? A) "I will massage the injection site after administration" B) "I will inject the medication into my abdomen" C) "I will use the same site for each injection" D) "I will aspirate before injecting the medication" Answer: B) "I will inject the medication into my abdomen" Rationale: Subcutaneous heparin should be injected into the abdomen at least 2 inches away from the umbilicus. The site should be rotated, not massaged (can cause bruising), and aspiration is not required for subcutaneous injections. ________________________________________ 8. A client is admitted with acute pancreatitis. Which finding is most concerning?