HESI RN
HESI RN Exit Exam Capstone Questions
Question 1 of 5
A client who is bedridden after a stroke is at risk for developing pressure ulcers. Which nursing intervention is most important in preventing this complication?
Correct Answer: B
Rationale: Repositioning the client every 2 hours is essential in preventing pressure ulcers in bedridden clients.
Question 2 of 5
The nurse observes that a client's wrist restraint is secured to the side rail of the bed. What action should the nurse take?
Correct Answer: B
Rationale: Restraints should always be secured to the bedframe, not the side rails, to prevent injury to the client in case the bed is adjusted.
Question 3 of 5
A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (A1C) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale of insulin aspart every 6 hours are prescribed. What actions should the nurse include in this client's plan of care?
Correct Answer: D
Rationale: Effective diabetes management involves comprehensive care, including proper foot care, insulin administration technique, and maintaining carbohydrate consistency with meals. All of these interventions are critical in reducing hyperglycemic episodes and managing diabetes.
Question 4 of 5
A teenager presents to the emergency department with palpitations after vaping at a party. The client is anxious, fearful, and hyperventilating. Which acid-base imbalance does the nurse anticipate the client developing?
Correct Answer: B
Rationale: Hyperventilation from anxiety or fear causes an excessive loss of CO2, leading to respiratory alkalosis. This shift in pH results from the rapid, shallow breathing that reduces the level of carbon dioxide in the blood. Respiratory acidosis would occur in cases of poor ventilation or CO2 retention, while metabolic acidosis/alkalosis relates to disturbances in bicarbonate, not breathing patterns.
Question 5 of 5
The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction?
Correct Answer: B
Rationale: The selection of a sliced turkey sandwich and canned pineapple shows an understanding of sodium restriction.
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