HESI Exit Exam 2024 QUESTIONS AND ANSWER
Terms in this set (722)
What PO2 value indicates
respiratory failure in adults?
PO2 < 60 mmHg
What blood
... [Show More] 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
HESI Exit Exam 2024
2/20
What are the common causes of
respiratory failure in peds?
C
H
D
R
DS
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.
HESI Exit Exam 2024
3/20
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?
Tachycardi
a
Tachypnea
Hypotensio
n 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
Dopami
ne
Dobutam
ine
Isoproter
enol
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
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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
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
4/20
d) "On the days that I eat green leafy veggies or calf cause constipation. Meats are an excellent source of iron. The client needs to take the
liver I can omit taking the iron supplement." iron supplements regardless of food intake.
b) Abdominal examination
c) Inserting NG tube
d) Thorough investigation of precipitating
events
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."
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 [Show Less]