HESI RN
HESI RN Exit Exam Capstone Questions
Question 1 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: The pillows along the side rails do not provide sufficient protection in the event of a seizure. The nurse should inform the UAP to remove the pillows and ensure proper padding of the side rails. This prevents injury, such as hitting the head or limbs during a seizure.
Question 2 of 5
A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement?
Correct Answer: D
Rationale: Intravenous fluids are essential for rehydrating an infant who is likely suffering from dehydration due to projectile vomiting. This condition, commonly related to pyloric stenosis, causes rapid fluid loss. Oral rehydration methods might not be sufficient or appropriate for such a young infant, especially if vomiting persists. IV therapy ensures controlled and adequate fluid replacement to stabilize the child.
Question 3 of 5
A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care?
Correct Answer: B
Rationale: Leukopenia, or a low white blood cell count, is a critical concern in clients undergoing radiation therapy due to increased risk of infection.
Question 4 of 5
The nurse is caring for a client with deep vein thrombosis (DVT) who is receiving anticoagulant therapy. Which intervention should the nurse implement to prevent complications?
Correct Answer: A
Rationale: Elevating the affected leg helps reduce swelling and improve venous return, which is important for preventing complications in clients with DVT. Other interventions, such as ambulation, are secondary to leg elevation.
Question 5 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.
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