HESI RN
HESI RN Exit Exam 2024 Quizlet Capstone Questions
Question 1 of 5
The nurse is assessing a client 2 hours postoperatively following an appendectomy. The nurse should intervene for which abnormal finding?
Correct Answer: C
Rationale: The correct answer is C. Oxygen saturation levels below 95% indicate hypoxia and require immediate intervention. A heart rate of 88 beats per minute, a blood pressure of 100/60, and a respiratory rate of 16 are within normal ranges and do not require immediate intervention. Oxygen saturation is a critical parameter reflecting the client's oxygenation status.
Question 2 of 5
The charge nurse is planning assignments on a medical unit. Which client should be assigned to the PN?
Correct Answer: C
Rationale: Irrigating and redressing a leg wound is a common task within the PN's scope of practice, making this assignment appropriate. Tasks like testing stool specimens for occult blood and assisting with ambulation of a client with a chest tube may require a higher level of training and assessment, typically performed by RNs. Admitting a client from the emergency room involves a comprehensive assessment and decision-making process, which is usually within the RN's responsibility.
Question 3 of 5
When asking an unlicensed assistive personnel (UAP) to assist a 69-year-old surgical client to ambulate for the first time, which statement by the nurse is appropriate?
Correct Answer: A
Rationale: The correct answer is A. Allowing the client to sit on the side of the bed before standing helps prevent dizziness and falls, especially during their first ambulation post-surgery. Choice B is incorrect because asking the client to take deep breaths when feeling dizzy may not address the underlying cause of the dizziness. Choice C is incorrect as it is unrelated to the task of assisting the client to ambulate for the first time. Choice D is incorrect because knowing how the client feels after sitting in the chair does not address the important step of assisting the client to stand up for the first time.
Question 4 of 5
A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse's response should be to
Correct Answer: D
Rationale: The correct response for the nurse in this situation is to discuss the boundaries of the therapeutic relationship with the client. By doing so, the nurse can reinforce professionalism, establish clear boundaries, and prevent ethical conflicts. Option A is incorrect because avoiding the client or unit does not address the issue at hand and may compromise patient care. Option B, while acknowledging the behavior, does not address the underlying reasons and boundaries. Option C, stating hospital policy, is not as therapeutic or client-centered as discussing the therapeutic relationship directly.
Question 5 of 5
A client recently started on warfarin therapy. What laboratory value is most important to monitor for this client?
Correct Answer: B
Rationale: Prothrombin time (PT) is the most important laboratory value to monitor for clients on warfarin therapy. PT helps determine how long it takes blood to clot and ensures the warfarin dose is within the therapeutic range to prevent either excessive bleeding or clotting. Monitoring platelet count is important for assessing the risk of bleeding, but PT is more specific to warfarin therapy. Creatinine level and BUN are indicators of kidney function and are not directly related to warfarin therapy.