HESI RN
RN HESI Exit Exam Capstone Questions
Question 1 of 5
A client with pneumonia is receiving oxygen therapy. What assessment finding requires immediate intervention?
Correct Answer: B
Rationale: The correct answer is B. An oxygen saturation of 89% indicates hypoxemia, which is below the normal range (usually 95-100%). This finding requires immediate intervention as it signifies inadequate oxygenation. Options A, C, and D are within normal limits and do not indicate an urgent need for intervention. Option A indicates a good oxygen saturation level, option C denotes a normal respiratory rate, and option D suggests a normal heart rate. Therefore, these options do not require immediate intervention compared to the critically low oxygen saturation level of 89% in option B.
Question 2 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 3 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 4 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: The correct answer is C) The medication must be continued so the fluid problem is controlled. Rationale: This response is the best because diuretics are essential in managing congestive heart failure by reducing fluid buildup in the body. Continual use of diuretics helps maintain optimal fluid balance and prevent complications associated with fluid retention, such as edema and shortness of breath. Option A is incorrect because the need for diuretics is based on the underlying condition, not solely on increased urination. Option B is incorrect as the duration of diuretic therapy varies depending on the individual's condition and should not be generalized. Option D is incorrect as it does not provide specific guidance on the importance of continuing diuretic therapy in managing congestive heart failure. In an educational context, understanding the rationale behind the importance of diuretic therapy in congestive heart failure management is crucial for nurses providing home care. Nurses must educate clients on the necessity of adhering to prescribed medications to effectively manage their condition and improve their quality of life.
Question 5 of 5
A client has been given a prescription for tetracycline HCL (Sumycin). The nurse should emphasize the client to
Correct Answer: C
Rationale: The correct answer is C: 'Monitor for signs of yellowing skin or eyes.' Tetracycline can cause hepatotoxicity, leading to jaundice which may present as yellowing of the skin or eyes. This is a serious side effect that the nurse should emphasize to the client. Choice A is incorrect because tetracycline should generally be taken on an empty stomach, not with food or milk. Choice B is also incorrect as tetracycline can cause photosensitivity, but it is not directly related to yellowing skin or eyes. Choice D is incorrect because tetracycline can cause yellow-brown discoloration of the teeth, but this is usually seen in children under 8 years of age, not a common concern for adult clients.