HESI RN Exit

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Sample questions from HESI RN Exit

This material has 150 questions with answers and rationales. Here are the first 5.

1. 1.At change of shift on a medical-surgical unit, the charge nurse receives reports on four clients. Which client should the charge nurse assess first?

   • A.A 42-year-old client 6 hours after thyroidectomy who is restless and reports tingling around the mouth, with a hoarse voice and inspiratory stridor
   • B.A 74-year-old client receiving warfarin for atrial fibrillation who has an INR of 4.1 and a small bruise at a venipuncture site
   • C.A 58-year-old client with pneumonia who has a temperature of 38.2 C, productive cough, and SpO2 93% on 2 L/min nasal cannula
   • D.A 67-year-old client with heart failure who gained 1 kg overnight and has bilateral ankle edema, SpO2 94% on room air, and no dyspnea

   Rationale: The recent thyroidectomy client has stridor and a hoarse voice, findings that suggest airway obstruction from postoperative edema or bleeding and require immediate assessment and intervention. The heart failure findings suggest fluid retention but no acute respiratory compromise is reported. The elevated INR and small bruise require prompt follow-up, but are less urgent without evidence of major bleeding. The pneumonia findings warrant ongoing care, but the reported oxygenation and symptoms are less immediately threatening.

2. 2.During a home health visit, a 76-year-old client with heart failure tells the nurse, "I stopped taking my water pill because I have to use the bathroom too often." The client has gained 2.3 kg in 4 days, has new bilateral crackles, and takes digoxin and furosemide. Which action should the nurse take first?

   • A.Arrange a routine follow-up visit in 1 week to evaluate adherence
   • B.Ask the client to take the missed furosemide dose immediately and resume the usual schedule tomorrow
   • C.Contact the prescriber to report the weight gain and new crackles, and clarify the medication plan
   • D.Teach the client to restrict fluids to 1 L daily until the weight returns to baseline

   Rationale: New crackles and rapid weight gain indicate worsening fluid overload, so the nurse should promptly communicate the change and obtain an authorized treatment plan. Advising an extra diuretic dose is not within the nurse's authority and may be unsafe, particularly with digoxin and potential electrolyte changes. A strict fluid limit should not be imposed without an individualized prescription. Waiting a week delays action for a potentially worsening cardiopulmonary condition.

3. 3.In a long-term care facility, an 81-year-old resident with mild dementia is scheduled for transfer to the emergency department after a fall. The resident is awake, recognizes the facility, and repeatedly says, "I do not want to go." The resident's adult child requests that staff proceed because the resident is "not capable of deciding." Which actions should the nurse take? Select all that apply.

   • A.Explain the reason for transfer and the risks of refusing in language the resident can understand
   • B.Notify the provider of the resident's refusal and request evaluation of decision-making capacity if needed
   • C.Use restraints to prevent the resident from leaving while the transfer is arranged
   • D.Assess the resident's ability to understand the proposed transfer and communicate a choice
   • E.Ask the adult child to sign consent because the resident has a dementia diagnosis
   • F.Document the resident's statements, assessment, teaching, and notifications

   Rationale: Decision-making capacity is specific to the decision and cannot be presumed absent solely because the resident has dementia, so the nurse should assess understanding and ability to communicate a choice. The resident should receive an understandable explanation of the proposed transfer and risks, and the provider should be notified to evaluate capacity and address the refusal. The child cannot automatically consent based only on being a relative, and restraints are not an appropriate response to a capable resident's refusal. Documentation should capture the resident's words, assessment, teaching, and notifications.

4. 4.A 6-year-old child with a new tracheostomy is admitted to a pediatric unit. The charge nurse is assigning care to an experienced registered nurse, a licensed practical nurse, and an unlicensed assistive personnel (UAP). Which task is appropriate to assign to the UAP?

   • A.Suction the tracheostomy when the child develops noisy respirations
   • B.Teach the parent how to clean the inner cannula
   • C.Assess the child's respiratory effort and determine whether the tracheostomy requires suctioning
   • D.Measure and record the child's oral intake and urine output

   Answer and rationale are in the full material.

5. 5.A provider prescribes a heparin infusion for a 59-year-old client with a new pulmonary embolism. The client's aPTT is 126 seconds (therapeutic range per protocol 60-80 seconds), and the client reports new flank pain. Which action should the nurse take first?

   • A.Administer the next scheduled dose of warfarin and reassess the pain
   • B.Pause the infusion and follow the bleeding-management protocol while notifying the provider
   • C.Decrease the infusion rate by half and repeat the aPTT in 6 hours
   • D.Document the aPTT and continue the infusion because the client has a pulmonary embolism

   Answer and rationale are in the full material.