HESI RN Exit Exam

Correct Answer A: Can predispose to dysrhythmias

Explanation:

Digoxin’s therapeutic and toxic effects are closely tied to potassium levels. When potassium is low, digoxin binds more readily to the sodium-potassium ATPase pump, intensifying its cardiac effects. This heightened sensitivity can lead to serious, potentially life-threatening dysrhythmias, such as atrial tachycardia with block, ventricular arrhythmias, or AV block. Maintaining adequate potassium intake and monitoring serum levels are essential to reduce the risk of digoxin toxicity and arrhythmias.

Why Other Options Are Wrong:

B) May lead to oliguria

Hypokalemia does not directly cause oliguria when combined with digoxin. Oliguria is more commonly associated with renal dysfunction or decreased perfusion from worsening heart failure, not this specific drug–electrolyte interaction.

C) May cause irritability and anxiety

These are nonspecific symptoms of many conditions and are not the primary concern with hypokalemia and digoxin use. The major clinical risk is arrhythmia, which poses an immediate threat to life.

D) Sometimes alters consciousness

Changes in consciousness can occur with digoxin toxicity, but they are secondary effects. The key risk factor potentiated by hypokalemia is cardiac dysrhythmia, which is much more dangerous and urgent to address.

Correct Answers:

B, C, E

Explanation of Correct Answers

B. Monitor blood pressure every 2 hours for hypertension.

Wilm’s tumor often affects renal function and can lead to hypertension due to increased renin secretion. Frequent monitoring is necessary to detect and manage preoperative complications.

C. Provide parents with simple explanations and repeat often.

Parents of young children facing a cancer diagnosis may experience high anxiety. Using simple, repeated explanations promotes understanding and supports coping during the preoperative period.

E. Measure the child's abdominal girth.

Abdominal girth is measured regularly to monitor tumor growth, detect increasing pressure, and assess for changes that could indicate complications

Why Other Options Are Incorrect

A. Explain expected side effects of postoperative chemotherapy.

Teaching about chemotherapy is important but is more relevant in the postoperative phase after surgical confirmation of treatment plans. Preoperatively, the focus is on surgical preparation and tumor monitoring.

D. Attend all healthcare provider and parent conferences.

While family conferences are important, it is not a direct preoperative nursing intervention for the child. The nurse may participate in coordination, but it is not a priority intervention specific to Wilm’s tumor care before surgery.

Correct Answers:

A. Current prescribed and over-the-counter medications; C. Methods currently used to treat constipation; D. Daily food and fluid intake; E. Level of physical activity and exercise

Explanation of Correct Answers

A. Current prescribed and over-the-counter medications

Many medications, such as opioids, calcium channel blockers, and iron supplements, cause constipation. Reviewing medications helps identify and modify possible contributing factors.

C. Methods currently used to treat constipation

Assessing what remedies the client already uses (laxatives, stool softeners, enemas, or home remedies) prevents duplication, overuse, or unsafe practices and provides insight into effectiveness.

D. Daily food and fluid intake

Low fiber intake and inadequate hydration are major contributors to constipation. Evaluating diet and fluid intake helps guide teaching about dietary modifications.

E. Level of physical activity and exercise

Physical inactivity slows peristalsis. Understanding the client’s mobility and activity patterns helps the nurse tailor recommendations for improving bowel regularity.

Why Other Option Is Wrong

B. Next scheduled visit with healthcare provider

While follow-up care is important, knowing when the next appointment is does not directly help the nurse determine the cause of constipation or guide immediate interventions. It is not essential data for formulating the care plan.

Correct Answer B: Assess for post operative arrhythmias

Explanation:

After surgical correction of a ventricular septal defect, the priority assessment is monitoring for postoperative arrhythmias. The surgical procedure involves incisions and suturing near the septum, which is close to the conduction pathways of the heart. This places the child at high risk for conduction disturbances such as heart block or dysrhythmias, which can be life-threatening if not promptly recognized and managed. Continuous ECG monitoring is essential in the immediate postoperative period.

Why Other Options Are Wrong:

A) Blanch nail beds for color and refill

While assessing perfusion and capillary refill is important, it is not as immediately critical as detecting arrhythmias, which can compromise cardiac output abruptly.

C) Auscultate for pulmonary congestion

Pulmonary congestion should be monitored for in the longer term, especially if residual defects or left-sided heart failure develops, but it is not the first priority right after surgery.

D) Monitor equality of peripheral pulses

Pulse equality is important after cardiac surgery to check for perfusion, but arrhythmias pose a more acute and life-threatening risk that must take priority in the immediate postoperative period.

Correct Answer:

A. Request that the mother leave the room.

Explanation of Correct Answer

A. The mother’s loud and forceful behavior disrupts the assessment and creates an environment where the client cannot freely express herself. The nurse’s primary duty is to advocate for the client’s autonomy, privacy, and safety. If the family member is interfering with care and pressuring decisions, the nurse should respectfully but firmly request that she leave the room so the client can participate in her own care. This restores control to the client and allows the nurse to focus on her needs without external influence.

Why Other Options Are Incorrect

B. Notify the charge nurse of the situation

This may be done if the situation escalates, but the bedside nurse has the responsibility to first take direct action. Involving the charge nurse immediately delays resolution and does not address the immediate disruption.

C. Request security to remove her from the room

This is unnecessary and too extreme unless the mother becomes aggressive or refuses to leave after being asked politely. It is not the first-line approach.

D. Tell the mother to stop speaking for the client

This might redirect the focus, but it does not resolve the loud and disruptive presence of the mother. Simply telling her to stop speaking may not restore the client’s privacy or autonomy as effectively as removing her from the room.

Correct Answer A: Her mother and sister have a history of breast cancer

Explanation:

Hormone replacement therapy (HRT) can reduce the risk of osteoporosis by maintaining estrogen levels, but it is contraindicated in women with a personal or strong family history of breast cancer. Estrogen therapy can stimulate hormone-sensitive breast tissue, increasing the risk of developing malignancy. In this case, having both a mother and sister with breast cancer represents a significant familial risk, making HRT unsafe.

Why Other Options Are Wrong:

B) She has a sedentary lifestyle

A sedentary lifestyle increases the risk of osteoporosis but is not a contraindication to HRT. Lifestyle modifications such as exercise are recommended regardless of treatment.

C) She has a history of osteoporosis

A history of osteoporosis is an indication, not a contraindication, for considering HRT. Other medications such as bisphosphonates may also be considered, but osteoporosis itself does not prevent HRT use.

D) She has a history of hypertension

While hypertension requires monitoring with any medication, it is not a contraindication for HRT. Blood pressure management can continue alongside treatment if otherwise appropriate.

Correct Answer B. Muffled heart sounds

Explanation:

Muffled heart sounds indicate possible cardiac tamponade or severe fluid accumulation compressing the heart. This is a life-threatening emergency because it impairs ventricular filling and cardiac output, leading to cardiovascular collapse if not treated promptly. In a cirrhotic client with ascites, fluid shifts and effusions can exacerbate this complication, requiring immediate intervention.

Why Other Options Are Wrong:

A. Jaundice skin tone

Jaundice is common in cirrhosis due to impaired bilirubin metabolism. While it requires monitoring and management, it is not immediately life-threatening compared to cardiac tamponade.

C. Pitting peripheral edema

Edema is expected in cirrhosis and ascites due to hypoalbuminemia and portal hypertension. It indicates fluid retention but does not require the same urgent intervention as muffled heart sounds.

D. Bilateral scleral edema

This is more consistent with scleral icterus (from jaundice), which reflects chronic liver dysfunction. It is significant but not an immediate emergency.

Correct Answer:

C. Muscle pain.

Explanation of Correct Answer

Muscle pain in a client taking lovastatin can indicate myopathy or rhabdomyolysis, a rare but potentially life-threatening adverse effect. Rhabdomyolysis involves muscle breakdown, which can lead to acute kidney injury from myoglobin release. This symptom requires immediate follow-up, discontinuation of the drug, and further evaluation. Prompt recognition and action prevent serious complications, making this the priority concern compared to other less severe side effects.

Why Other Options Are Incorrect

A. Abdominal cramps.

GI upset is a common side effect of statins and usually mild. While it may be uncomfortable, it does not pose an immediate threat to the client’s health.

B. Diarrhea and flatulence.

These are common, non-life-threatening side effects of lovastatin. They may require supportive care but are not urgent or dangerous compared to muscle pain.

D. Altered taste.

Changes in taste perception can occur but are not clinically dangerous. This side effect is minor and does not require urgent intervention.

Correct Answer B. Primary nursing.

Why this is the correct answer:

B. Primary nursing.

In primary nursing, one nurse assumes responsibility for planning, directing, and coordinating the care of a group of clients over a 24-hour period. This model promotes continuity of care, accountability, and a strong nurse–client relationship because the same nurse is responsible for overseeing the care plan and ensuring it is carried out consistently.

Why the other options are incorrect:

A. Team nursing.

In team nursing, care is provided collaboratively by a team led by an RN. The RN delegates tasks to other team members (LPNs, UAPs), but does not personally assume 24-hour responsibility for planning all client care.

C. Case management.

Case management focuses on coordinating care and resources across the healthcare system, usually for clients with complex or chronic needs. It is not centered on direct 24-hour bedside care delivery.

D. Functional nursing.

Functional nursing divides tasks among staff members (e.g., one nurse gives all medications, another provides hygiene care). It emphasizes efficiency, not continuity of care, and does not involve one nurse planning care for 24 hours.