HESI RN
RN HESI Exit Exam Capstone Questions
Question 1 of 5
A client with hypocalcemia is receiving calcium gluconate. What assessment finding requires immediate intervention?
Correct Answer: B
Rationale: Wheezing and stridor may indicate a severe allergic reaction to calcium gluconate, such as anaphylaxis, which requires immediate intervention. While hypocalcemia can present with decreased deep tendon reflexes and positive Chvostek's sign, these findings do not indicate an immediate life-threatening situation. Decreased bowel sounds are not directly related to a severe reaction to calcium gluconate and do not require immediate intervention.
Question 2 of 5
A client receiving total parenteral nutrition (TPN) is experiencing nausea and vomiting. What is the nurse's first action?
Correct Answer: D
Rationale: The correct first action for the nurse to take when a client receiving TPN is experiencing nausea and vomiting is to check the client's TPN bag for solution accuracy. This is crucial to ensure that the correct solution is being administered and to address any potential errors. Checking the blood glucose level or administering an antiemetic may be necessary interventions but addressing the TPN bag's accuracy should be the priority to prevent any complications related to incorrect TPN solution.
Question 3 of 5
A client with hypertension is prescribed a low-sodium diet. What is the most important instruction for the nurse to provide?
Correct Answer: D
Rationale: The correct answer is D. Avoiding processed foods and canned soups is crucial for a client with hypertension on a low-sodium diet because these foods are typically high in sodium content. Fresh fruits and vegetables are generally healthy choices but may still contain some natural sodium. While limiting sodium intake to 2 grams per day is important, specifically avoiding processed foods and canned soups is more critical in this situation. Drinking water is essential for overall health but is not the most important instruction when focusing on reducing sodium intake.
Question 4 of 5
The nurse is caring for a client who requires a mechanical ventilator for breathing. The high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?
Correct Answer: B
Rationale: The correct answer is to perform a quick assessment of the client's condition when the high-pressure alarm goes off on the ventilator. This assessment is crucial to determine the cause of the alarm and the client's current status. Option A is incorrect because disconnecting the client from the ventilator without assessing the situation can be harmful. Option C is incorrect as the nurse should first assess the client before seeking additional help. Option D is incorrect because resetting the alarm without understanding the underlying issue may lead to potential risks to the client.
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: Failed to generate a rationale of 500+ characters after 5 retries.