HESI RN EXIT EXAM (750 QUESTIONS ANSWERS) (HESI EXIT RN EXAM 2023

The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? a- Ensure that the UAP has placed the pillows effectively to protect the client. b- Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows. a- Assume responsibility for placing the pillows while the UAP completes another task. b- Ask the UAP to use some of the pillows to prop the client in a side lying position. Rationale: The nurse should instruct the UAP to pad the side rails with soft blankest because the use of pillows could result in suffocation and would need to be removed at the onset of the seizure. The nurse can delegate paddling the side rails to the UAP 4. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up? a- Describes life without purpose b- Complains of nausea and loss of appetite c- States is often fatigued and drowsy d- Exhibits an increase in sweating. Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor that is known to increase the risk of suicidal thinking in adolescents and young adults with major depressive disorder. B, C and D are side effects 5. A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client‟s teaching plan? a- Further evaluation involving surgery may be needed b- A pelvic exam is also needed before cancer is ruled out c- Pap smear evaluation should be continued every six month d- One additional negative pap smear in six months is needed. Rationale: An abdominal mass in a client with a family history for ovarian cancer should be evaluated carefully 6. A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan? a- Explain how to use communication tools. b- Teach tracheal suctioning techniques c- Encourage self-care and independence. d- Demonstrate how to clean tracheostomy site. Rationale: Suctioning helps to clear secretions and maintain an open airway, which is critical. 7. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client‟s respiratory rate is 14 breaths / minute. What action should the nurse implement? a- Encourage the client to take deep breaths b- Remove the mask to deflate the bag c- Increase the liter flow of oxygen d- Document the assessment data Rational: reservoir bag should not deflate completely during inspiration and the client‟s respiratory rate is within normal limits. 8. During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first? a- Give the client 4 ounces of orange juice b- Call 911 to summon emergency assistance c- Check the client for lacerations or fractures d- Asses clients blood sugar level Rationale: After the client falls, the nurse should immediately assess for the possibility of injuries and provide first aid as needed 9. At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? a- Ensure preoperative lab results are available b- Start prescribed IV with lactated Ringer‟s c- Inform the anesthesia care provider d- Contact the client‟s obstetrician. Rationale: Surgical preoperative instruction includes NPO after midnight the day of surgery to decrease the risk of aspiration should vomiting occur during anesthesia. While it is possible the C-section will be done on schedule or rescheduled for later in the day, the anesthesia provider should be notified first. 10. After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first?