HESI RN Exit Exam 2023

Correct Answer: D

Rationale: The correct action for the nurse to implement is to document the assessment data. In this scenario, the findings indicate that the partial rebreather mask is functioning correctly as the reservoir bag should not deflate completely during inspiration. Additionally, the client's respiratory rate of 14 breaths/minute falls within the normal range. There is no need to encourage the client to take deep breaths, as the respiratory rate is normal, and doing so may disrupt the client's breathing pattern. Removing the mask to deflate the bag or increasing the liter flow of oxygen are unnecessary actions based on the assessment findings.

Correct Answer: A

Rationale: The correct answer is A: 'Have you had any difficulty starting your urinary stream?' This question is the most relevant as difficulty starting urination can indicate an obstruction, which aligns with the client's current condition of postrenal obstruction causing acute renal failure. Choice B is incorrect as a history of kidney stones may not be directly related to the current obstruction. Choice C, asking about daily fluid intake, is not specific to the current issue of postrenal obstruction. Choice D inquires about previous urinary tract infections, which are not directly related to the current acute renal failure caused by postrenal obstruction.

Correct Answer: C

Rationale: A serum bicarbonate level of 18 mEq/L is concerning in a client with COPD receiving supplemental oxygen as it indicates metabolic acidosis, which can occur due to the body compensating for chronic respiratory acidosis. This condition requires immediate intervention to restore the acid-base balance. Choice A, serum sodium of 135 mEq/L, is within normal range (135-145 mEq/L) and not directly related to COPD or oxygen therapy. Choice B, serum potassium of 4.0 mEq/L, falls within the normal range (3.5-5.0 mEq/L) and is not typically affected by COPD or oxygen therapy. Choice D, serum glucose of 300 mg/dl, though elevated, is not directly related to COPD or oxygen therapy and would require management but is not the most concerning value in this scenario.

Correct Answer: A

Rationale: A fever of 100.4�F is a clinical finding that requires immediate intervention in a client with ESRD scheduled for hemodialysis. Fever may indicate an underlying infection, which can be severe in individuals with compromised renal function. Prompt assessment and treatment are essential to prevent worsening of the infection and potential complications. Heart rate, blood pressure, and respiratory rate are also important parameters to monitor in clients with ESRD, but in this scenario, the fever takes precedence due to its potential to indicate a critical condition that requires urgent attention.

Correct Answer: A

Rationale: A serum potassium level of 6.5 mEq/L is concerning in a client with COPD exacerbation as it may lead to life-threatening arrhythmias, requiring immediate intervention. Hyperkalemia can cause cardiac arrhythmias, which pose a significant risk to the patient's life. Options B, C, and D are not typically associated with immediate life-threatening risks in the context of a COPD exacerbation.