HESI RN
HESI RN Exit Exam Capstone Questions
Question 1 of 5
A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the therapeutic response, which assessment should the nurse obtain?
Correct Answer: D
Rationale: Lactulose is used to reduce ammonia levels, so consciousness is an indicator of efficacy.
Question 2 of 5
Which intervention should the nurse include in the care plan for a child with tetanus?
Correct Answer: D
Rationale: Tetanus causes severe muscle spasms and sensitivity to stimuli, so minimizing stimuli like light, sound, and touch can help prevent painful spasms. Monitoring vital signs and administering antibiotics are important but managing stimuli is crucial for the child's comfort and safety.
Question 3 of 5
The nurse is caring for a client with acute pancreatitis who is reporting severe abdominal pain. Which nursing intervention should the nurse implement first?
Correct Answer: B
Rationale: Pain relief is a priority in clients with acute pancreatitis. Administering prescribed pain medication is the first intervention to improve comfort and reduce pain, which can help stabilize the client's condition.
Question 4 of 5
An older client with SIRS has a temperature of 101.8�F, a heart rate of 110 beats per minute, and a respiratory rate of 24 breaths per minute. Which additional finding is most important to report to the healthcare provider?
Correct Answer: A
Rationale: A serum creatinine level of 2.0 mg/dL indicates possible acute kidney injury, which can occur during severe systemic inflammatory response syndrome (SIRS). Reporting this value promptly allows for interventions to prevent further renal damage.
Question 5 of 5
A client admitted with left-sided heart failure presents with shortness of breath and pink frothy sputum. Which assessment finding requires immediate intervention?
Correct Answer: C
Rationale: Pink frothy sputum is a sign of pulmonary edema, which needs immediate intervention to prevent respiratory failure.
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