HESI RN
RN HESI Exit Exam Capstone Questions
Question 1 of 5
A client is receiving continuous intravenous heparin for a deep vein thrombosis. Which laboratory result should the nurse monitor to ensure therapeutic heparin levels?
Correct Answer: B
Rationale: The activated partial thromboplastin time (aPTT) is the most accurate measure of heparin's therapeutic effect. Heparin increases the time it takes for blood to clot, and the aPTT helps determine whether the dose is within the desired range for anticoagulation therapy. Monitoring the INR, hemoglobin, or platelet count is not specific to assessing therapeutic heparin levels and may not reflect the anticoagulant effect of heparin.
Question 2 of 5
Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?
Correct Answer: D
Rationale: The correct answer is D: Upper body muscle strength. The ability to use a trapeze bar requires adequate upper body strength to support the weight and facilitate repositioning. While assessing pain, coordination, and cognitive status are important, the priority is determining if the client can physically manage the trapeze bar safely. Without sufficient upper body muscle strength, the client may not be able to use the trapeze bar effectively and safely. Assessing balance and coordination is also important but secondary to ensuring the client has the required upper body strength. Cognitive status is crucial for understanding instructions related to using the trapeze bar, but it is not the most critical assessment in this scenario. Pain assessment is essential for overall care but does not directly impact the client's ability to use a trapeze bar like upper body muscle strength does.
Question 3 of 5
A young adult was hit in the temporal area with a baseball bat and is being monitored for signs of a closed head injury. Which finding indicates a developing epidural hematoma?
Correct Answer: B
Rationale: The correct answer is B. Altered consciousness within the first 24 hours after a temporal injury is a classic sign of epidural hematoma, which is a neurosurgical emergency. This finding occurs due to the rapid expansion of the hematoma, causing compression of the brain. Nausea and vomiting (choice A) are more commonly associated with other types of head injuries, such as concussion. Severe headache and blurred vision (choice C) are symptoms seen in various head injuries but are not specific to epidural hematomas. Loss of motor function on the affected side (choice D) is more indicative of a different type of head injury, such as a contusion or intracerebral hematoma.
Question 4 of 5
The nurse assesses a client's wound. What type of wound requires immediate intervention by the nurse?
Correct Answer: A
Rationale: Lacerations, especially deep ones, are prone to bacterial contamination and may require immediate intervention to prevent infection. Abrasions, contusions, and ulcerations are not as likely to lead to immediate serious complications like infections as lacerations.
Question 5 of 5
While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse¢â‚¬â„¢s best response?
Correct Answer: C
Rationale: Diuretics must be continued as long as the fluid problem persists to prevent heart failure symptoms.
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