HESI RN
HESI RN Exit Exam Capstone Questions
Question 1 of 5
The nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease (COPD). Which intervention is most important to promote effective breathing?
Correct Answer: A
Rationale: In caring for a client with an exacerbation of COPD, the most important intervention to promote effective breathing is to encourage diaphragmatic breathing (Option A). Diaphragmatic breathing helps the client maximize the use of their diaphragm, the main muscle of respiration, leading to improved oxygen exchange and ventilation. This technique also reduces the work of breathing and helps the client achieve better oxygen saturation levels. Increasing the client's oxygen flow rate (Option B) may seem beneficial, but it does not address the underlying issue of ineffective breathing mechanics that diaphragmatic breathing targets. Having the client perform range of motion exercises (Option C) and placing them in a supine position (Option D) can actually worsen respiratory distress in COPD by reducing lung expansion and increasing the workload of breathing. In an educational context, understanding the importance of diaphragmatic breathing in COPD management highlights the significance of optimizing respiratory function through evidence-based interventions. By prioritizing this technique, nurses can effectively support clients with COPD in improving their breathing patterns and overall respiratory status, ultimately enhancing patient outcomes and quality of life.
Question 2 of 5
The nurse is administering an intradermal injection for a tuberculosis skin test. Which technique should the nurse use?
Correct Answer: B
Rationale: In administering an intradermal injection for a tuberculosis skin test, the nurse should use a 27-gauge needle at a 15-degree angle, which is the correct answer (B). This technique is appropriate for intradermal injections because the skin in this area is thin, and a smaller needle size and a shallow angle are needed to ensure accurate placement of the medication just below the skin's surface. Option A (A 25-gauge needle at a 90-degree angle) is incorrect because a 90-degree angle and a larger needle size are more suitable for intramuscular injections, not intradermal ones. Option C (A 22-gauge needle at a 45-degree angle) is also incorrect as the needle gauge is too large for intradermal injections, which require a smaller gauge needle. Option D (A 20-gauge needle at a 90-degree angle) is not appropriate for intradermal injections as it is a larger needle size and a 90-degree angle, which is more suitable for intramuscular injections. Educationally, understanding the correct technique for administering intradermal injections is crucial for nurses to ensure accurate delivery of medications and to prevent complications. It is important for nurses to be knowledgeable about the appropriate needle size, angle, and injection site for different types of injections to provide safe and effective patient care.
Question 3 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 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: 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 5 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.