Questions 9

HESI RN

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HESI RN Exit Exam Capstone Questions

Question 1 of 5

An older client with SIRS has a temperature of 101.8°F, a heart rate of 110 beats per minute, and a respiratory rate of 24 breaths per minute. Which additional finding is most important to report to the healthcare provider?

Correct Answer: A

Rationale: A serum creatinine level of 2.0 mg/dL indicates possible acute kidney injury, which can occur during severe systemic inflammatory response syndrome (SIRS). Reporting this value promptly allows for interventions to prevent further renal damage.

Question 2 of 5

The nurse observes that a client's wrist restraint is secured to the side rail of the bed. What action should the nurse take?

Correct Answer: B

Rationale: Restraints should always be secured to the bedframe, not the side rails, to prevent injury to the client in case the bed is adjusted.

Question 3 of 5

A client with heart failure receiving furosemide develops muscle weakness. What is the nurse's priority action?

Correct Answer: B

Rationale: Muscle weakness in a client receiving furosemide (a diuretic) is often a sign of hypokalemia, as furosemide increases potassium loss. Monitoring potassium levels is essential to identify and address any imbalances and prevent complications such as arrhythmias.

Question 4 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: Drinking liquids before surgery can increase the risk of aspiration during anesthesia. Therefore, the anesthesia care provider must be informed immediately to determine how to proceed, as this could delay or alter the surgical plan.

Question 5 of 5

A client with type 1 diabetes mellitus is admitted to the emergency department with confusion, sweating, and a blood sugar level of 45 mg/dL. What is the nurse's priority action?

Correct Answer: A

Rationale: A blood sugar level of 45 mg/dL indicates severe hypoglycemia, which can lead to life-threatening complications if not treated immediately. The priority is to administer IV dextrose to rapidly increase the blood sugar level. Offering a carbohydrate snack may follow once the client is stable.

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