HESI RN
HESI RN Exit Exam Capstone Questions
Question 1 of 5
The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal
Correct Answer: A
Rationale: In this scenario, the correct answer is A) S3 ventricular gallop. When assessing a client with congestive heart failure, the presence of an S3 gallop is indicative of volume overload and impaired ventricular function. This extra heart sound occurs in early diastole during rapid ventricular filling. Option B) Apical click is not typically associated with congestive heart failure but may be heard in conditions like mitral valve prolapse. Option C) Systolic murmur is more likely to be heard in conditions like aortic stenosis or mitral regurgitation, not specific to congestive heart failure. Option D) Split S2 is related to the closure of the aortic and pulmonic valves and is not a common finding in congestive heart failure. Educationally, understanding heart sounds is crucial for nurses to accurately assess and monitor patients with cardiovascular conditions. Recognizing the significance of specific heart sounds can guide treatment decisions and interventions for clients with congestive heart failure. Practice and repetition in auscultation skills are essential for nurses to confidently identify abnormal heart sounds in clinical practice.
Question 2 of 5
To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must
Correct Answer: A
Rationale: In the context of suctioning a tracheostomy to prevent unnecessary hypoxia, the correct answer is A) Apply suction for no more than 10 seconds. This is essential because prolonged suctioning can lead to hypoxia due to the removal of oxygen-rich air from the lungs. Limiting suction time helps maintain adequate oxygenation for the patient. Option B) Maintain sterile technique is important for infection control but is not directly related to preventing hypoxia during suctioning. Option C) Lubricate 3 to 4 inches of the catheter tip is incorrect as excessive lubrication can lead to aspiration of the lubricant into the patient's airway, causing respiratory distress. Option D) Withdraw catheter in a circular motion is incorrect as it does not address the key issue of limiting suction time to prevent hypoxia. From an educational perspective, it is crucial for nurses to understand the rationale behind limiting suction time during tracheostomy care to ensure optimal patient outcomes. By adhering to this best practice, nurses can minimize the risk of complications such as hypoxia and maintain the patient's respiratory status during suctioning procedures. This knowledge is vital for providing safe and effective care to patients with tracheostomies in various healthcare settings.
Question 3 of 5
The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take?
Correct Answer: A
Rationale: In this scenario, the correct action for the nurse to take when a client develops urticaria (hives) after starting a blood transfusion is to stop the infusion immediately (Option A). This is crucial because urticaria can be an early sign of a transfusion reaction, such as an allergic reaction or hemolytic reaction, which can be life-threatening if not addressed promptly. Stopping the infusion allows the nurse to prevent further administration of the blood product that may be causing the reaction and to assess the client's condition more closely. Slowing the rate of infusion (Option B) or administering Benadryl and continuing the infusion (Option D) are not appropriate initial actions when a transfusion reaction is suspected, as they do not address the urgent need to stop the potential trigger and evaluate the client. Taking vital signs and observing for further deterioration (Option C) is important but should come after stopping the infusion to ensure the client's safety and to gather more information to guide subsequent interventions. In an educational context, understanding the appropriate actions during a transfusion reaction is crucial for nurses caring for clients receiving blood products. Recognizing early signs of adverse reactions, such as urticaria, and knowing the immediate steps to take can prevent serious complications and ensure client safety during transfusion therapy.
Question 4 of 5
The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction?
Correct Answer: B
Rationale: The correct answer is option B, which is a sliced turkey sandwich and canned pineapple. This lunch choice demonstrates an understanding of sodium restriction for a client with congestive heart failure because both turkey and canned pineapple are low in sodium compared to the other options. Turkey is a lean protein choice that is naturally low in sodium, and canned pineapple typically contains less sodium than processed or canned meats and dairy products. Option A, a cheese sandwich with a glass of 2% milk, contains higher amounts of sodium due to the cheese and milk. Cheese and milk products are generally higher in sodium, which is not suitable for a client with congestive heart failure on a sodium-restricted diet. Option C, a cheeseburger and baked potato, is high in sodium due to the processed cheese and likely added salt in the burger. Baked potatoes can also be high in sodium if salted heavily, making this option inappropriate for a client needing to restrict their sodium intake. Option D, mushroom pizza and ice cream, is also high in sodium. Pizza typically contains high amounts of sodium in the crust, cheese, and toppings. Ice cream can also be a significant source of sodium, especially if it is a processed or flavored variety. In an educational context, understanding proper nutrition for clients with congestive heart failure is crucial in managing their condition and improving their quality of life. Teaching clients about sodium restriction helps prevent fluid retention and reduces the workload on the heart, ultimately supporting better heart function and overall health. Encouraging low-sodium food choices like lean proteins and fresh fruits can help clients make healthier decisions and manage their condition effectively.
Question 5 of 5
When teaching a group of mothers of young children about emergency care for poisoning, which of the following statements should be included?
Correct Answer: C
Rationale: The correct statement to include when teaching mothers of young children about emergency care for poisoning is to "Call the Poison Control Center prior to any interventions." This is the best course of action because Poison Control Centers have expert toxicologists who can provide specific guidance tailored to the type of poison ingested and the individual's age and weight. They can advise on whether inducing vomiting is appropriate or if other steps need to be taken. Option A, to induce vomiting immediately after poison ingestion, is not recommended as it can actually worsen the situation by causing aspiration or further damaging the esophagus. Option B, calling the Poison Control Center after inducing vomiting, is also incorrect because the order of actions is crucial in poisoning cases. Consulting experts before taking any action is important to ensure the correct steps are followed. Option D, taking the child to the emergency department before calling the Poison Control Center, is not the best choice because Poison Control Centers can provide immediate, expert advice over the phone, which can be crucial in saving time and potentially the child's life. In an educational context, it is vital to emphasize the importance of quick and informed action in cases of poisoning. Teaching parents to contact Poison Control Centers first can help prevent unnecessary harm and ensure the best possible outcome for the child. Prompt and correct intervention can make a significant difference in the management of poisoning emergencies.