HESI RN
HESI RN Exit Exam 2024 Capstone Questions
Question 1 of 5
A nurse is planning discharge teaching for a client with congestive heart failure (CHF). Which dietary instruction should the nurse provide?
Correct Answer: A
Rationale: The correct answer is A: Limit sodium intake to reduce fluid retention. Limiting sodium intake is crucial for managing congestive heart failure (CHF) as it helps reduce fluid retention. Excess fluid retention can worsen CHF by increasing the workload on the heart. Choice B is incorrect because while protein is essential for overall health, it is not directly related to managing CHF. Choice C is incorrect because potassium, although important, is not the primary focus in managing CHF. Choice D is incorrect because increasing fluid intake can exacerbate fluid retention in CHF patients.
Question 2 of 5
The nurse is caring for a client with deep vein thrombosis (DVT) who is receiving heparin therapy. Which assessment finding requires immediate intervention by the nurse?
Correct Answer: D
Rationale: Hematuria is a sign of bleeding, which is a potential complication of heparin therapy. Immediate intervention is required to manage the bleeding and adjust the heparin dosage if necessary. Localized warmth, calf pain, and swelling in the affected leg are common findings in clients with DVT and receiving heparin therapy. While these symptoms should be monitored, hematuria indicates a more serious issue requiring immediate attention.
Question 3 of 5
The nurse is caring for a client with a traumatic brain injury who is receiving mechanical ventilation. Which assessment finding indicates that the client may be experiencing increased intracranial pressure (ICP)?
Correct Answer: A
Rationale: Increased lethargy is a sign of worsening intracranial pressure, which can be life-threatening in clients with brain injuries. As ICP rises, it can lead to decreased level of consciousness, such as lethargy or even coma. Choices B, C, and D are not indicative of increased ICP. A normal respiratory rate, response to verbal stimuli, and equal reactive pupils do not specifically point towards increased intracranial pressure.
Question 4 of 5
The nurse is providing discharge instructions to a client with chronic venous insufficiency. Which recommendation should the nurse include to help prevent complications?
Correct Answer: B
Rationale: The correct recommendation for a client with chronic venous insufficiency to prevent complications is to wear compression stockings. Compression stockings help improve venous circulation and prevent the worsening of symptoms. While elevating the legs is also beneficial, the priority intervention in preventing complications is wearing compression stockings. Using a heating pad on the legs can actually worsen the condition by dilating blood vessels, and massaging the legs daily can potentially damage fragile skin in clients with chronic venous insufficiency.
Question 5 of 5
A client is receiving IV fluid therapy for dehydration. Which assessment finding indicates that the client's fluid status is improving?
Correct Answer: A
Rationale: An increase in urine output is a positive sign that the client's hydration status is improving. It indicates that the kidneys are functioning well and that fluid therapy is effective. Increased urine output helps to eliminate excess fluid and waste products from the body. Choices B, C, and D are incorrect. Feeling more thirsty (choice B) is a sign of dehydration, not improvement. A decrease in blood pressure (choice C) and an increase in heart rate (choice D) are not typically indicative of improving fluid status during IV fluid therapy for dehydration.