HESI RN
HESI RN Exit Exam Capstone Questions
Question 1 of 5
A teenager presents to the emergency department with palpitations after vaping at a party. The client is anxious, fearful, and hyperventilating. Which acid-base imbalance does the nurse anticipate the client developing?
Correct Answer: B
Rationale: Hyperventilation from anxiety or fear causes an excessive loss of CO2, leading to respiratory alkalosis. This shift in pH results from the rapid, shallow breathing that reduces the level of carbon dioxide in the blood. Respiratory acidosis would occur in cases of poor ventilation or CO2 retention, while metabolic acidosis/alkalosis relates to disturbances in bicarbonate, not breathing patterns.
Question 2 of 5
A client scheduled for a bronchoscopy in the morning is anxious and asking the nurse numerous questions about the procedure. Which intervention has the highest priority in preparing the client for the procedure?
Correct Answer: C
Rationale: In preparing a client for a bronchoscopy, the highest priority intervention is option C: Instruct the client to write down the questions. This is essential because it allows the client to organize their thoughts, address their concerns, and feel more empowered and in control of the situation. By writing down questions, the client is more likely to remember them and can effectively communicate with healthcare providers during the pre-procedure preparation. Option A, providing detailed education about the procedure, is important but may not address the immediate anxiety and questions of the client. Option B, administering anti-anxiety medication, should not be the first line of intervention as it does not address the root cause of the anxiety and should only be used if necessary. Option D, reassuring the client about the safety of the procedure, is important but may not directly address the client's immediate concerns and questions. In an educational context, this rationale emphasizes the importance of effective communication and empowering clients to take an active role in their care. Encouraging clients to write down their questions promotes patient-centered care and helps healthcare providers address individual needs and concerns, leading to better outcomes and patient satisfaction.
Question 3 of 5
The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instruction should the nurse provide the UAP who is working with the nurse?
Correct Answer: D
Rationale: The correct answer is D) Continue to measure the client's vital signs every thirty minutes until the transfusion is complete. This instruction is crucial because monitoring vital signs closely during a blood transfusion helps the nurse to quickly identify any signs of a transfusion reaction, such as fever, chills, rash, or shortness of breath. By measuring vital signs every thirty minutes, the nurse can promptly intervene if any complications arise, ensuring the client's safety. Option A) Encouraging the client to increase fluid intake is not the correct instruction for the UAP in this scenario. While adequate hydration is important, it is not directly related to monitoring for a transfusion reaction. Option B) Documenting the absence of a reaction is important but should be done by the nurse, not the UAP. UAPs are typically not responsible for documenting clinical assessments or findings. Option C) Notifying the nurse if the client develops a fever is not the best instruction for the UAP. The UAP should focus on continuous monitoring of vital signs rather than waiting for the client to develop a fever before notifying the nurse. In an educational context, this question highlights the importance of close monitoring during blood transfusions and the specific responsibilities of different members of the healthcare team in ensuring patient safety and quality care. It emphasizes the significance of timely and accurate vital sign assessments in detecting and managing potential transfusion reactions.
Question 4 of 5
A client asks the nurse for information about reducing risk factors for BPH. Which information should the nurse provide?
Correct Answer: A
Rationale: In the context of BPH (Benign Prostatic Hyperplasia), increasing physical activity is the most appropriate answer. Regular physical activity helps in maintaining a healthy weight and can reduce the risk of developing BPH. Exercise also improves overall health and circulation, which can have a positive impact on prostate health. Decreasing alcohol consumption (option B) can be beneficial for overall health but is not directly linked to reducing the risk factors for BPH. Similarly, reducing intake of dairy products (option C) and avoiding caffeine and spicy foods (option D) may help alleviate symptoms for some individuals with BPH, but they are not primary strategies for reducing the risk factors. From an educational perspective, it is important for nurses to provide evidence-based information to clients. Understanding the rationale behind each option can help nurses convey accurate information to clients seeking guidance on reducing their risk for BPH. By emphasizing the importance of physical activity, nurses can empower clients to make informed lifestyle choices that promote prostate health and overall well-being.
Question 5 of 5
While assessing a client who is admitted with heart failure and pulmonary edema, the nurse identifies dependent peripheral edema, an irregular heart rate, and a persistent cough that produces pink blood-tinged sputum. After initiating continuous telemetry and positioning the client, which intervention should the nurse implement?
Correct Answer: D
Rationale: The client's cough producing pink, frothy sputum is indicative of pulmonary edema, which needs immediate treatment. Obtaining a sputum sample helps identify any infection that may be contributing to the pulmonary issues. Administering diuretics and notifying the provider are also important, but sputum analysis will guide specific treatment.