HESI RN
HESI RN Exit Exam Capstone Questions
Question 1 of 5
A nurse is caring for a client with a chest tube following lung surgery. What is the most important intervention to ensure the chest tube functions properly?
Correct Answer: C
Rationale: In caring for a client with a chest tube post-lung surgery, maintaining proper chest tube function is critical for the client's respiratory status and overall recovery. The most important intervention to ensure the chest tube functions properly is to keep the drainage system below chest level (Option C). This is essential to facilitate proper drainage of air or fluid from the pleural space, creating a gravity-driven flow that prevents backflow or blockages in the tubing. Clamping the tube if there is excessive drainage (Option A) is incorrect because clamping can lead to a tension pneumothorax, a life-threatening complication. Emptying the drainage chamber every 2 hours (Option B) is important but not the most critical intervention as the key lies in maintaining the positioning of the drainage system. Milking the tube to prevent clots (Option D) is incorrect as this action can damage the tube and lead to clots or blockages. Educationally, understanding the rationale behind each intervention enhances a nurse's clinical decision-making skills and promotes safe and effective patient care. Emphasizing the importance of proper chest tube management in postoperative care ensures optimal patient outcomes and reduces the risk of complications associated with chest tube placement.
Question 2 of 5
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement?
Correct Answer: B
Rationale: In this scenario, the correct action for the nurse to implement is Option B: Inform the UAP that the pillows should be removed immediately. This is the correct choice because placing pillows along the side rails during a seizure can pose a significant safety risk to the client. In the event of a seizure, the client may thrash uncontrollably and could potentially injure themselves on the pillows or become entangled in them, leading to further harm. Option A is incorrect because leaving the pillows in place without addressing the safety concern puts the client at risk. Option C is incorrect as firm padding could still pose a risk of injury during a seizure. Option D is also incorrect as padding the side rails does not address the immediate safety issue presented by the pillows. From an educational perspective, this question highlights the importance of understanding safety precautions for clients with seizure disorders. It emphasizes the nurse's role in ensuring a safe environment and providing appropriate guidance to unlicensed personnel to prevent potential harm to the client.
Question 3 of 5
At 0600 while admitting a woman for a scheduled repeat cesarean section, the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?
Correct Answer: B
Rationale: In this scenario, the correct action for the nurse to take first is to inform the anesthesia care provider (Option B). The reason for this is that anesthesia providers need to be aware of the patient's recent intake of food or drink to prevent complications during surgery, such as aspiration. By notifying the anesthesia care provider, they can determine if it is safe to proceed with the cesarean section or if any precautions need to be taken. Canceling the surgery (Option A) would be an extreme measure at this point and may not be necessary if proper precautions can be taken. Asking the client if she has had other liquids (Option C) is important but not the first priority in this situation. Proceeding with routine preparations (Option D) without addressing the coffee intake could potentially lead to complications during surgery. From an educational perspective, this question highlights the importance of thorough preoperative assessments and communication between healthcare team members to ensure patient safety and optimal outcomes. Nurses need to understand the implications of patients consuming food or drink before surgery and the appropriate steps to take in such situations to prevent complications.
Question 4 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: In the context of the HESI RN Exit Exam Capstone, understanding the importance of surgical hand scrub duration is crucial for maintaining aseptic technique and preventing surgical site infections. The correct answer, B) Extend scrub time to 5 minutes, is based on evidence-based practice guidelines that recommend a 5-minute scrub to effectively reduce microbial flora on the hands prior to surgery. Option A) Proceed with surgery preparation is incorrect because a 3-minute scrub is not considered sufficient to adequately reduce the microbial flora on the hands. Option C) Use an alcohol-based hand sanitizer is also incorrect because while alcohol-based sanitizers are effective in certain situations, they are not a substitute for a thorough surgical hand scrub before surgery. Option D) Scrub time depends on the type of surgery is incorrect because regardless of the type of surgery, a 5-minute hand scrub is generally recommended to ensure proper hand hygiene practices are followed consistently. Educationally, this question highlights the importance of adhering to evidence-based guidelines in healthcare settings to promote patient safety and prevent healthcare-associated infections. Understanding and following proper hand hygiene protocols is a fundamental aspect of nursing practice that directly impacts patient outcomes and quality of care.
Question 5 of 5
The healthcare provider prescribes an IV infusion of isoproterenol in D5W at 300 mcg/hour. How many ml/hour should the nurse set the pump to?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) 75 ml/hour. To calculate the infusion rate, we need to consider the concentration of the medication in the solution. Isoproterenol is ordered at 300 mcg/hour and is diluted in D5W. To determine the mL/hour rate, we need to convert the mcg to mg (1 mcg = 0.001 mg) and then calculate the total volume of the solution. Considering the concentration of isoproterenol and the diluent, the correct calculation is as follows: 300 mcg/hour = 0.3 mg/hour 0.3 mg x 1000 mcg = 300 mcg in 1 ml So, 0.3 mg is in 1 ml of the solution. Therefore, the nurse should set the pump to 75 ml/hour to deliver the prescribed dose of isoproterenol. Now, let's analyze the other options: A) 100 ml/hour: This is incorrect because it does not consider the concentration of the medication and would result in an incorrect dosage. C) 60 ml/hour: This option is incorrect as it does not account for the correct rate of infusion needed for the prescribed dose. D) 125 ml/hour: This option is incorrect as it would result in an incorrect dosage due to not considering the concentration of the medication. Understanding medication calculations is crucial for nurses to ensure patient safety and provide accurate care. Nurses must be able to calculate infusion rates correctly to administer medications safely and effectively. Practice and proficiency in medication calculations are essential skills for nursing practice.