HESI RN Exit Exam Capstone

Questions 101

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HESI RN Exit Exam Capstone Questions

Question 1 of 5

A client is suspected of having a stroke. What is the nurse's priority action?

Correct Answer: B

Rationale: A neurological assessment is the priority when a stroke is suspected to determine the extent of brain injury and identify any immediate risks, such as impaired airway, speech deficits, or loss of motor function. Early recognition of these signs is essential for timely intervention and to guide further treatment like the administration of tPA, if appropriate.

Question 2 of 5

The nurse is caring for a client with a chest tube following surgery. The nurse should intervene if which of the following is observed?

Correct Answer: C

Rationale: The chest drainage system should always be kept below chest level to ensure proper drainage.

Question 3 of 5

The nurse is caring for a preterm newborn with nasal flaring, grunting, and sternal retractions. After administering surfactant, which assessment is most important for the nurse to monitor?

Correct Answer: C

Rationale: Surfactant therapy is used to improve lung function and gas exchange in premature infants with respiratory distress. Monitoring arterial blood gases is essential to assess the effectiveness of the treatment and ensure adequate oxygenation.

Question 4 of 5

A client with heart failure is prescribed spironolactone. What is the nurse's priority intervention?

Correct Answer: B

Rationale: Spironolactone is a potassium-sparing diuretic, so the nurse should closely monitor for signs of hyperkalemia, which can lead to cardiac arrhythmias.

Question 5 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: Diaphragmatic breathing helps improve lung expansion and oxygen exchange, promoting more effective breathing in clients with COPD. Increasing oxygen flow rate is not always appropriate and can worsen hypercapnia in these clients.

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A client is receiving 30 mg of enoxaparin subcutaneously twice a day. In assessing adverse effects of the medication, which serum laboratory value is most important for the nurse to monitor?
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A client with bipolar disorder is prescribed lithium. What should the nurse teach the client about lithium toxicity?

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