HESI RN
HESI RN Exit Exam Capstone Questions
Question 1 of 5
A client is admitted with pneumonia and is started on antibiotics. After 3 days, the client reports difficulty breathing and a rash. What is the nurse's first action?
Correct Answer: B
Rationale: In this scenario, the nurse's first action should be to discontinue the antibiotic (option B). This is because the client is exhibiting signs of a potential allergic reaction to the medication, as evidenced by the development of a rash and difficulty breathing. Discontinuing the antibiotic is crucial to prevent further adverse reactions and ensure the client's safety. Administering epinephrine (option A) is not appropriate as the client's symptoms do not indicate an anaphylactic reaction that would warrant the use of epinephrine. Assessing the client's oxygen saturation (option C) is important, but in this case, discontinuing the potentially offending medication takes precedence to address the immediate allergic reaction. Calling the healthcare provider (option D) is important, but not the first action to take when the client is experiencing respiratory distress and a rash. Educationally, this question highlights the importance of recognizing and managing allergic reactions to medications promptly in clinical practice. It emphasizes the need for nurses to prioritize patient safety by taking swift and appropriate actions when faced with signs of adverse drug reactions. Understanding the appropriate steps to take in such situations is crucial for providing high-quality patient care.
Question 2 of 5
A nurse is caring for a client with a chest tube following lung surgery. What is the most important intervention to ensure the chest tube functions properly?
Correct Answer: C
Rationale: In caring for a client with a chest tube post-lung surgery, maintaining proper chest tube function is critical for the client's respiratory status and overall recovery. The most important intervention to ensure the chest tube functions properly is to keep the drainage system below chest level (Option C). This is essential to facilitate proper drainage of air or fluid from the pleural space, creating a gravity-driven flow that prevents backflow or blockages in the tubing. Clamping the tube if there is excessive drainage (Option A) is incorrect because clamping can lead to a tension pneumothorax, a life-threatening complication. Emptying the drainage chamber every 2 hours (Option B) is important but not the most critical intervention as the key lies in maintaining the positioning of the drainage system. Milking the tube to prevent clots (Option D) is incorrect as this action can damage the tube and lead to clots or blockages. Educationally, understanding the rationale behind each intervention enhances a nurse's clinical decision-making skills and promotes safe and effective patient care. Emphasizing the importance of proper chest tube management in postoperative care ensures optimal patient outcomes and reduces the risk of complications associated with chest tube placement.
Question 3 of 5
The nurse is administering an intradermal injection for a tuberculosis skin test. Which technique should the nurse use?
Correct Answer: B
Rationale: In administering an intradermal injection for a tuberculosis skin test, the nurse should use a 27-gauge needle at a 15-degree angle, which is the correct answer (B). This technique is appropriate for intradermal injections because the skin in this area is thin, and a smaller needle size and a shallow angle are needed to ensure accurate placement of the medication just below the skin's surface. Option A (A 25-gauge needle at a 90-degree angle) is incorrect because a 90-degree angle and a larger needle size are more suitable for intramuscular injections, not intradermal ones. Option C (A 22-gauge needle at a 45-degree angle) is also incorrect as the needle gauge is too large for intradermal injections, which require a smaller gauge needle. Option D (A 20-gauge needle at a 90-degree angle) is not appropriate for intradermal injections as it is a larger needle size and a 90-degree angle, which is more suitable for intramuscular injections. Educationally, understanding the correct technique for administering intradermal injections is crucial for nurses to ensure accurate delivery of medications and to prevent complications. It is important for nurses to be knowledgeable about the appropriate needle size, angle, and injection site for different types of injections to provide safe and effective patient care.
Question 4 of 5
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement?
Correct Answer: B
Rationale: In this scenario, the correct action for the nurse to implement is Option B: Inform the UAP that the pillows should be removed immediately. This is the correct choice because placing pillows along the side rails during a seizure can pose a significant safety risk to the client. In the event of a seizure, the client may thrash uncontrollably and could potentially injure themselves on the pillows or become entangled in them, leading to further harm. Option A is incorrect because leaving the pillows in place without addressing the safety concern puts the client at risk. Option C is incorrect as firm padding could still pose a risk of injury during a seizure. Option D is also incorrect as padding the side rails does not address the immediate safety issue presented by the pillows. From an educational perspective, this question highlights the importance of understanding safety precautions for clients with seizure disorders. It emphasizes the nurse's role in ensuring a safe environment and providing appropriate guidance to unlicensed personnel to prevent potential harm to the client.
Question 5 of 5
At 0600 while admitting a woman for a scheduled repeat cesarean section, the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?
Correct Answer: B
Rationale: In this scenario, the correct action for the nurse to take first is to inform the anesthesia care provider (Option B). The reason for this is that anesthesia providers need to be aware of the patient's recent intake of food or drink to prevent complications during surgery, such as aspiration. By notifying the anesthesia care provider, they can determine if it is safe to proceed with the cesarean section or if any precautions need to be taken. Canceling the surgery (Option A) would be an extreme measure at this point and may not be necessary if proper precautions can be taken. Asking the client if she has had other liquids (Option C) is important but not the first priority in this situation. Proceeding with routine preparations (Option D) without addressing the coffee intake could potentially lead to complications during surgery. From an educational perspective, this question highlights the importance of thorough preoperative assessments and communication between healthcare team members to ensure patient safety and optimal outcomes. Nurses need to understand the implications of patients consuming food or drink before surgery and the appropriate steps to take in such situations to prevent complications.