HESI RN
HESI RN Exit Exam 2023 Capstone Questions
Question 1 of 5
A client has suspected compartment syndrome of the right lower leg. What is the nurse's priority intervention?
Correct Answer: B
Rationale: In a suspected case of compartment syndrome, the nurse's priority intervention is to loosen any restrictive dressings on the leg. This action helps to relieve pressure within the affected compartment, improve circulation, and prevent permanent damage. Elevating the leg may further increase pressure, preparing for emergency surgery is premature without proper assessment and diagnosis, and administering pain medication should come after addressing the primary issue of relieving pressure.
Question 2 of 5
While auscultating heart sounds, the nurse hears a swishing sound. How should this sound be documented?
Correct Answer: B
Rationale: The correct answer is B: 'Murmur.' A murmur is a swishing sound heard during auscultation, typically caused by turbulent blood flow through the heart or valves. Choices C and D, 'S3 sound' and 'S4 sound,' refer to specific heart sounds associated with different cardiac conditions, not the general description of a swishing sound. Choice A, 'Heart murmur,' is redundant as 'murmur' alone is sufficient to describe the swishing sound heard.
Question 3 of 5
A client with schizophrenia is experiencing auditory hallucinations. What is the nurse's best response?
Correct Answer: B
Rationale: The best response for a client with schizophrenia experiencing auditory hallucinations is to acknowledge the client's feelings and ask what the voices are saying. This approach helps build rapport with the client, demonstrates empathy, and allows the nurse to assess the content of the hallucinations. Understanding the content is crucial to determine whether the client is at risk of harm. Encouraging the client to ignore the voices (Choice A) may invalidate their experience. Redirecting the conversation (Choice C) may not address the underlying issue of the hallucinations. Offering reassurance (Choice D) without understanding the content may overlook potential risks.
Question 4 of 5
The nurse is caring for a client with chronic renal failure who is receiving dialysis. The client reports muscle cramps and tingling in the hands. Which laboratory result should the nurse monitor to identify the cause of these symptoms?
Correct Answer: B
Rationale: Muscle cramps and tingling in clients with chronic renal failure are often associated with hypocalcemia. Monitoring calcium levels is crucial to identify imbalances and manage symptoms appropriately. Sodium, phosphate, and potassium levels are important in renal failure but are not directly related to the symptoms of muscle cramps and tingling reported by the client.
Question 5 of 5
While changing a client's chest tube dressing, the nurse notes a cracking sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take?
Correct Answer: D
Rationale: When a nurse observes crepitus around a chest tube site, it could indicate subcutaneous emphysema, a potentially serious condition where air gets trapped under the skin. Measuring the area of swelling and crackling is important as it helps monitor the progression of subcutaneous emphysema. Applying a pressure dressing (choice A) might not address the underlying cause and could potentially worsen the condition. Administering an oral antihistamine (choice B) is not indicated for crepitus at a chest tube site. Assessing for allergies to topical cleaning agents (choice C) is important but not the immediate priority when crepitus is observed.
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