HESI RN
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 observes that a client's wrist restraint is secured to the side rail of the bed. What action should the nurse take?
Correct Answer: B
Rationale: Restraints should always be secured to the bedframe, not the side rails, to prevent injury to the client in case the bed is adjusted.
Question 3 of 5
To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must
Correct Answer: A
Rationale: Suctioning for more than 10 seconds can cause hypoxia, so it should be limited to 10 seconds at most.
Question 4 of 5
A client with 42-week gestation refuses induction. What is the most important action the nurse should take?
Correct Answer: A
Rationale: Supporting the client's birth plan helps reduce anxiety while ensuring informed decision-making.
Question 5 of 5
A client is admitted with ascites, malnutrition, and recent complaints of spitting up blood. What assessment finding warrants immediate intervention by the nurse?
Correct Answer: C
Rationale: A round and tight abdomen suggests fluid accumulation from ascites, which could signal a more severe underlying condition requiring immediate intervention.
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