HESI RN
HESI RN Exit Exam Capstone Questions
Question 1 of 5
A client with adrenal insufficiency is admitted to the ICU with acute adrenal crisis. The client's vital signs include heart rate 138 bpm and BP 80/60. What is the nurse's first intervention?
Correct Answer: B
Rationale: An IV fluid bolus stabilizes blood pressure during adrenal crisis.
Question 2 of 5
Which intervention should the nurse include in the care plan for a child with tetanus?
Correct Answer: D
Rationale: Tetanus causes severe muscle spasms and sensitivity to stimuli, so minimizing stimuli like light, sound, and touch can help prevent painful spasms. Monitoring vital signs and administering antibiotics are important but managing stimuli is crucial for the child's comfort and safety.
Question 3 of 5
To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must
Correct Answer: A
Rationale: Suctioning for more than 10 seconds can cause hypoxia, so it should be limited to 10 seconds at most.
Question 4 of 5
The nurse is providing care for a client with severe anemia. Which assessment finding requires immediate intervention?
Correct Answer: C
Rationale: Shortness of breath is a sign that the anemia is severe enough to impair oxygenation. Immediate intervention is needed to address this potentially life-threatening complication.
Question 5 of 5
A scrub nurse preparing for the first surgery of the day asks if a 3-minute surgical hand scrub is adequate. What should the circulating nurse advise?
Correct Answer: B
Rationale: The circulating nurse should advise the scrub nurse to extend the hand scrub to 5 minutes for thorough preparation, particularly for the first surgery of the day.
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