HESI RN Exit Exam

1. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hour IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client's heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the finding to the surgeon. Which action should the nurse implement first? - Increase the infusion rate of Lactated Ringer's solution. 2. An adult male who fell 20 feet from the roof of this home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU) the nurse notes that the suction control chamber is bubbling at the 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? - Add sterile water to the suction control chamber. 3. A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which action should the nurse take first? - Begin supplemental oxygen. 4. A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply) - Headache and tremors - Irregular heart rate - Pallor and diaphoresis 5. An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration that the nurse should report to the healthcare provider? - Skin tenting occurs when the client's forearm is pinched. 6. After an in-service about electronic health record (EHR) security and safeguarding client information, the nurse observes a colleague going home with printed copies of client information in a uniform pocket. Which action should the nurse take? - File a detailed incident report with the specific hiring facility. 7. The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicate the program is effective? - Clients who incurred disease complications promptly received rehabilitation. 8. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement first? - Assess the delivery mechanism of the oxygen tank, tubing, and cannula. 9. Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse? - When I get out of bed quickly, I feel a little dizzy." 10. An older adult male who is in his early 70's is admitted to the emergency department because of a COPD exacerbation. This client is struggling to breathe and the healthcare team is preparing for endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provide the nurse a copy of the client's living will. Which action should the nurse take? - Notify the healthcare provider of the client's wishes. 11. An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond? - Advice the client to maintain bedrest so that safety can be ensured.