HESI RN EXIT EXAM ALL VERSIONS INCLUDED WITH
RATIONALE
What PO2 value indicates respiratory failure in adults?
PO2 < 60 mmHg
What blood value indicates hypercapnia?
PCO2 > 45 mmHg
What condition occurs when the PO2 is < 60 mmHg (acute hypoxemia), the CO2 tension
rises > 50 mmHg (acute hypercarbia, hypercapnia) & the pH drops < 7.35, or both?
Acute respiratory failure
What are the S/S of respiratory failure in adults?
Dyspnea, SOB
Tachypnea
Intercostal & sternal retractions
Cyanosis
Tachycardia
Cough that produces sputum
Fatigue
Fever
Crackles, wheezes
Chest pain (especially when trying to deep breathe)
Hypotension
Confusion
Agitation, restlessness
What are the common causes of respiratory failure in peds?
CHD
RDS
Infection, sepsis
NM diseases
Trauma, burns
Aspiration
FVO & dehydration
Anesthesia & narcotic OD
Structural anomalies resulting in airway obstruction
What percentage of O2 should a child in severe respiratory distress receive?
100% O2
What is shock?
Widespread, serious reduction of tissue perfusion, which leads to generalized impairment
of cellular function.
,What is the most common cause of shock?
Hypovolemia
What causes septic shock?
Release of endotoxins from bacteria, which act on the nerves in peripheral vascular spaces,
causing vascular pooling, reduced venous return, decreased CO & results in poor systemic
perfusion.
What is the goal of tx for hypovolemic shock?
Quick restoration of CO & tissue perfusion.
It's important to differentiate between hypovolemic & cardiogenic shock. How might the
RN determine the existence of cardiogenic shock?
H/o MI with LV failure or possible cardiomyopathy, with S/S of pulmonary edema.
If a pt is in cardiogenic shock, what might result from administration of volume-expanding
fluids, and what intervention can the RN expect to perform in the event of such an
occurrence?
Pulmonary edema -- administer meds to manage preload, contractility and/or afterload.
For example, to decrease afterload, nitroprusside may be given.
What are 5 assessment findings occur in most shock pt's?
Tachycardia
Tachypnea
Hypotension
Cool, clammy skin
Decreased urine output
Once circulating volume is restored, vasopressors may be given to increase venous return.
What are the main drugs that are used?
Epi & NE
Dopamine
Dobutamine
Isoproterenol
What is the established minimum renal output per hour?
30 mL/hr
What are 4 measurable criteria that are the major expected outcomes of a shock crisis?
MAP 80-90 mmHg
PO2 > 50 mmHg
CVP 2-6 mmHg H2O
Urine output ≥ 30 mL/hr
What is DIC?
A coagulation disorder in which there's paradoxical thrombosis & hemorrhage.
What medication is used to tx DIC?
Heparin
The RN assesses a pt with the admitting dx of bipolar affective disorder, mania. Which pt
S/S require the RN's immediate action?
a) Incessant talking & sexual innuendos
b) Grandiose delusions & poor concentration
c) Outlandish behaviors & inappropriate dress
d) Nonstop physical activity & poor nutritional intake
,d) Nonstop physical activity & poor nutritional intake
Rationale:
Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy,
decreased need for sleep, and impaired ability to concentrate or complete a single train of
thought. The client's mood is predominantly elevated, expansive, or irritable. All of the
options reflect a client's possible symptoms. However, the correct option clearly presents a
problem that compromises physiological integrity and needs to be addressed immediately.
The RN is caring for a pt who was involuntarily hospitalized to a mental health unit & is
scheduled for ECT. The RN notes that the informed consent hasn't been obtained for the
procedure. Based on this information, what is the RN's best determination in care
planning?
a) The informed consent doesn't need to be obtained.
b) The informed consent would be obtained from the family.
c) The informed consent needs to be obtained from the pt.
d) The PCP will provide informed consent.
c) The informed consent needs to be obtained from the pt.
Rationale:
Clients who are admitted involuntarily to a mental health unit do not lose their right to
informed consent. Clients must be considered legally competent until they have been
declared incompetent through a legal proceeding. The best determination for the nurse to
make is to obtain the informed consent from the client.
A pt presents to the ED with UGI bleeding & in moderate distress. In care planning, what is
the priority RN action for this pt?
a) VS assessment
b) Abdominal examination
c) Inserting NG tube
d) Thorough investigation of precipitating events
a) VS assessment
Rationale:
The priority nursing action is to assess the vital signs. This would provide information
about the amount of blood loss that has occurred and provide a baseline by which to
monitor the progress of treatment. The client may be unable to provide subjective data
until the immediate physical needs are met. Although an abdominal examination and an
assessment of the precipitating events may be necessary, these actions are not the priority.
Insertion of a nasogastric tube is not the priority and will require a primary health care
provider's prescription; in addition, the vital signs would be checked before performing
this procedure.
The RN is caring for a pt with anorexia nervosa. Which behavior is characteristic of this
disorder & reflects anxiety mgmt?
a) Engaging in immoral acts
b) Always reinforcing self-approval
c) Observing rigid rules & regulations
d) Having the need to always make the right decision
, c) Observing rigid rules & regulations
Rationale:
Clients with anorexia nervosa have the desire to please others. Their need to be correct or
perfect interferes with rational decision-making processes. These clients are moralistic.
Rules and rituals help these clients manage their anxiety.
The RN provides instructions to a malnourished pregnant pt regarding Fe2+
supplementation. Which pt statement indicates an understanding of the instructions?
a) "Iron supplements will give me diarrhea."
b) "Meat doesn't provide iron & should be avoided."
c) "The iron is best absorbed if taken on an empty stomach."
d) "On the days that I eat green leafy veggies or calf liver I can omit taking the iron
supplement."
c) "The iron is best absorbed if taken on an empty stomach."
Rationale:
Iron is needed to allow for transfer of adequate iron to the fetus and to permit expansion of
the maternal red blood cell mass. During pregnancy, the relative excess of plasma causes a
decrease in the hemoglobin concentration and hematocrit, known as physiological anemia
of pregnancy. This is a normal adaptation during pregnancy. Iron is best absorbed if taken
on an empty stomach. Taking it with a fluid high in ascorbic acid such as tomato juice
enhances absorption. Iron supplements usually cause constipation. Meats are an excellent
source of iron. The client needs to take the iron supplements regardless of food intake.
Levothyroxine is prescribed for a pt with hypothyroidism. Upon review of the pt's record,
the RN notes that the pt is taking warfarin. Which modification to the POC would the RN
review with the pt's HCP?
a) Decreased dosage of levothyroxine
b) Increased dosage of levothyroxine
c) Decreased dosage of warfarin
d) Increased dosage of warfarin
c) Decreased dosage of warfarin
Rationale:
Levothyroxine accelerates the degradation of vitamin K–dependent clotting factors. As a
result, the effects of warfarin are enhanced. If thyroid hormone replacement therapy is
instituted in a client who has been taking warfarin, the dosage of warfarin would be
reduced.
The RN is teaching a pt with emphysema about positions that help breathing during
dyspneic episodes. The RN instructs the pt that which positions alleviate dyspnea? (SATA)
a) Sitting up & leaning on a table
b) Standing & leaning against a wall
c) Lying supine with feet elevated
d) Sitting up with elbows resting on knees
e) Lying on the back in low-Fowler's position
a) Sitting up & leaning on a table
b) Standing & leaning against a wall
RATIONALE
What PO2 value indicates respiratory failure in adults?
PO2 < 60 mmHg
What blood value indicates hypercapnia?
PCO2 > 45 mmHg
What condition occurs when the PO2 is < 60 mmHg (acute hypoxemia), the CO2 tension
rises > 50 mmHg (acute hypercarbia, hypercapnia) & the pH drops < 7.35, or both?
Acute respiratory failure
What are the S/S of respiratory failure in adults?
Dyspnea, SOB
Tachypnea
Intercostal & sternal retractions
Cyanosis
Tachycardia
Cough that produces sputum
Fatigue
Fever
Crackles, wheezes
Chest pain (especially when trying to deep breathe)
Hypotension
Confusion
Agitation, restlessness
What are the common causes of respiratory failure in peds?
CHD
RDS
Infection, sepsis
NM diseases
Trauma, burns
Aspiration
FVO & dehydration
Anesthesia & narcotic OD
Structural anomalies resulting in airway obstruction
What percentage of O2 should a child in severe respiratory distress receive?
100% O2
What is shock?
Widespread, serious reduction of tissue perfusion, which leads to generalized impairment
of cellular function.
,What is the most common cause of shock?
Hypovolemia
What causes septic shock?
Release of endotoxins from bacteria, which act on the nerves in peripheral vascular spaces,
causing vascular pooling, reduced venous return, decreased CO & results in poor systemic
perfusion.
What is the goal of tx for hypovolemic shock?
Quick restoration of CO & tissue perfusion.
It's important to differentiate between hypovolemic & cardiogenic shock. How might the
RN determine the existence of cardiogenic shock?
H/o MI with LV failure or possible cardiomyopathy, with S/S of pulmonary edema.
If a pt is in cardiogenic shock, what might result from administration of volume-expanding
fluids, and what intervention can the RN expect to perform in the event of such an
occurrence?
Pulmonary edema -- administer meds to manage preload, contractility and/or afterload.
For example, to decrease afterload, nitroprusside may be given.
What are 5 assessment findings occur in most shock pt's?
Tachycardia
Tachypnea
Hypotension
Cool, clammy skin
Decreased urine output
Once circulating volume is restored, vasopressors may be given to increase venous return.
What are the main drugs that are used?
Epi & NE
Dopamine
Dobutamine
Isoproterenol
What is the established minimum renal output per hour?
30 mL/hr
What are 4 measurable criteria that are the major expected outcomes of a shock crisis?
MAP 80-90 mmHg
PO2 > 50 mmHg
CVP 2-6 mmHg H2O
Urine output ≥ 30 mL/hr
What is DIC?
A coagulation disorder in which there's paradoxical thrombosis & hemorrhage.
What medication is used to tx DIC?
Heparin
The RN assesses a pt with the admitting dx of bipolar affective disorder, mania. Which pt
S/S require the RN's immediate action?
a) Incessant talking & sexual innuendos
b) Grandiose delusions & poor concentration
c) Outlandish behaviors & inappropriate dress
d) Nonstop physical activity & poor nutritional intake
,d) Nonstop physical activity & poor nutritional intake
Rationale:
Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy,
decreased need for sleep, and impaired ability to concentrate or complete a single train of
thought. The client's mood is predominantly elevated, expansive, or irritable. All of the
options reflect a client's possible symptoms. However, the correct option clearly presents a
problem that compromises physiological integrity and needs to be addressed immediately.
The RN is caring for a pt who was involuntarily hospitalized to a mental health unit & is
scheduled for ECT. The RN notes that the informed consent hasn't been obtained for the
procedure. Based on this information, what is the RN's best determination in care
planning?
a) The informed consent doesn't need to be obtained.
b) The informed consent would be obtained from the family.
c) The informed consent needs to be obtained from the pt.
d) The PCP will provide informed consent.
c) The informed consent needs to be obtained from the pt.
Rationale:
Clients who are admitted involuntarily to a mental health unit do not lose their right to
informed consent. Clients must be considered legally competent until they have been
declared incompetent through a legal proceeding. The best determination for the nurse to
make is to obtain the informed consent from the client.
A pt presents to the ED with UGI bleeding & in moderate distress. In care planning, what is
the priority RN action for this pt?
a) VS assessment
b) Abdominal examination
c) Inserting NG tube
d) Thorough investigation of precipitating events
a) VS assessment
Rationale:
The priority nursing action is to assess the vital signs. This would provide information
about the amount of blood loss that has occurred and provide a baseline by which to
monitor the progress of treatment. The client may be unable to provide subjective data
until the immediate physical needs are met. Although an abdominal examination and an
assessment of the precipitating events may be necessary, these actions are not the priority.
Insertion of a nasogastric tube is not the priority and will require a primary health care
provider's prescription; in addition, the vital signs would be checked before performing
this procedure.
The RN is caring for a pt with anorexia nervosa. Which behavior is characteristic of this
disorder & reflects anxiety mgmt?
a) Engaging in immoral acts
b) Always reinforcing self-approval
c) Observing rigid rules & regulations
d) Having the need to always make the right decision
, c) Observing rigid rules & regulations
Rationale:
Clients with anorexia nervosa have the desire to please others. Their need to be correct or
perfect interferes with rational decision-making processes. These clients are moralistic.
Rules and rituals help these clients manage their anxiety.
The RN provides instructions to a malnourished pregnant pt regarding Fe2+
supplementation. Which pt statement indicates an understanding of the instructions?
a) "Iron supplements will give me diarrhea."
b) "Meat doesn't provide iron & should be avoided."
c) "The iron is best absorbed if taken on an empty stomach."
d) "On the days that I eat green leafy veggies or calf liver I can omit taking the iron
supplement."
c) "The iron is best absorbed if taken on an empty stomach."
Rationale:
Iron is needed to allow for transfer of adequate iron to the fetus and to permit expansion of
the maternal red blood cell mass. During pregnancy, the relative excess of plasma causes a
decrease in the hemoglobin concentration and hematocrit, known as physiological anemia
of pregnancy. This is a normal adaptation during pregnancy. Iron is best absorbed if taken
on an empty stomach. Taking it with a fluid high in ascorbic acid such as tomato juice
enhances absorption. Iron supplements usually cause constipation. Meats are an excellent
source of iron. The client needs to take the iron supplements regardless of food intake.
Levothyroxine is prescribed for a pt with hypothyroidism. Upon review of the pt's record,
the RN notes that the pt is taking warfarin. Which modification to the POC would the RN
review with the pt's HCP?
a) Decreased dosage of levothyroxine
b) Increased dosage of levothyroxine
c) Decreased dosage of warfarin
d) Increased dosage of warfarin
c) Decreased dosage of warfarin
Rationale:
Levothyroxine accelerates the degradation of vitamin K–dependent clotting factors. As a
result, the effects of warfarin are enhanced. If thyroid hormone replacement therapy is
instituted in a client who has been taking warfarin, the dosage of warfarin would be
reduced.
The RN is teaching a pt with emphysema about positions that help breathing during
dyspneic episodes. The RN instructs the pt that which positions alleviate dyspnea? (SATA)
a) Sitting up & leaning on a table
b) Standing & leaning against a wall
c) Lying supine with feet elevated
d) Sitting up with elbows resting on knees
e) Lying on the back in low-Fowler's position
a) Sitting up & leaning on a table
b) Standing & leaning against a wall
