HESI RN
HESI RN Exit Exam 2023 Capstone Questions
Question 1 of 5
A client is admitted with a severe burn injury. What is the nurse's priority intervention?
Correct Answer: B
Rationale: The correct answer is B: Administer intravenous fluids. In a client with severe burn injury, the priority intervention is to administer intravenous fluids to prevent shock. Monitoring urine output (Choice A) is important but not the priority. Applying cool, moist compresses (Choice C) can be beneficial but is not the priority over fluid resuscitation. Covering the burn area with a sterile dressing (Choice D) is important for wound care but is not the immediate priority in managing severe burns.
Question 2 of 5
A client with hypothyroidism is prescribed levothyroxine. What assessment finding suggests the medication is effective?
Correct Answer: B
Rationale: The correct answer is B: Decreased fatigue and improved energy levels. Levothyroxine is a medication used to treat hypothyroidism by providing the body with the thyroid hormone it lacks. Therefore, a positive response to the medication would manifest as decreased fatigue and improved energy levels due to the correction of the thyroid hormone imbalance. Choices A, C, and D are incorrect because improved tolerance to cold, reduced anxiety, and increased sensitivity to heat are not direct indicators of the effectiveness of levothyroxine in managing hypothyroidism.
Question 3 of 5
A client with pneumonia is receiving antibiotics and oxygen therapy. What assessment finding requires immediate intervention?
Correct Answer: B
Rationale: An oxygen saturation of 88% indicates hypoxemia, which is a critical condition requiring immediate intervention to improve oxygenation. Hypoxemia can lead to tissue hypoxia and further complications. A productive cough with yellow sputum is common in pneumonia but may not require immediate intervention unless it worsens or is associated with other concerning symptoms. A respiratory rate of 20 breaths per minute is within the normal range, indicating adequate ventilation. A heart rate of 90 beats per minute is also within a normal range and may not require immediate intervention unless it is accompanied by other abnormal findings.
Question 4 of 5
A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is?
Correct Answer: D
Rationale: In clients with altered renal function being treated at home, weekly weight is the most accurate indicator of fluid balance. Fluid retention or loss can significantly affect weight, making it a reliable measure. Choices A, B, and C are not as accurate indicators of fluid balance as weekly weight. Intake and output differences can vary in accuracy and may not capture all aspects of fluid balance. Changes in mucous membranes and skin turgor can be influenced by factors other than fluid balance, making them less precise indicators.
Question 5 of 5
While assessing several clients in a long-term health care facility, which client is at the highest risk for developing decubitus ulcers?
Correct Answer: A
Rationale: The correct answer is A: A 79-year-old malnourished client on bed rest. This client is at the highest risk for developing decubitus ulcers due to being malnourished and on bed rest, leading to decreased mobility and poor nutrition. This combination puts the client at significant risk for skin breakdown and pressure ulcers. Choice B is incorrect because although obesity is a risk factor for developing pressure ulcers, immobility and poor nutrition are higher risk factors. Choice C is incorrect as incontinence can contribute to skin breakdown but is not as high a risk factor as immobility and poor nutrition. Choice D is incorrect as an ambulatory client, even if diabetic, has better mobility than a bedridden client and is at lower risk for developing decubitus ulcers.