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
A teenager presents to the emergency department with palpitations after vaping at a party. The client is anxious, fearful, and hyperventilating. Which acid-base imbalance does the nurse anticipate the client developing?
Correct Answer: B
Rationale: Hyperventilation from anxiety or fear causes an excessive loss of CO2, leading to respiratory alkalosis. This shift in pH results from the rapid, shallow breathing that reduces the level of carbon dioxide in the blood. Respiratory acidosis would occur in cases of poor ventilation or CO2 retention, while metabolic acidosis/alkalosis relates to disturbances in bicarbonate, not breathing patterns.
Question 3 of 5
The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instruction should the nurse provide the UAP who is working with the nurse?
Correct Answer: D
Rationale: Monitoring vital signs throughout a transfusion is critical, as reactions can occur later in the process. The UAP should continue to check vital signs regularly to ensure that any delayed reaction is promptly detected.
Question 4 of 5
A young woman with multiple sclerosis just received several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. What teaching should the nurse provide?
Correct Answer: A
Rationale: Immunizations can sometimes trigger relapses in multiple sclerosis due to the activation of the immune system. Extra rest can help manage these symptoms. While increased fluid intake may be helpful, the nurse should focus on explaining the connection between immunizations and MS symptoms.
Question 5 of 5
The nurse is caring for a client with pancreatitis who is receiving total parenteral nutrition (TPN). Which assessment finding requires immediate intervention by the nurse?
Correct Answer: B
Rationale: Weakness and shakiness can indicate hypoglycemia, a potential complication of TPN. Immediate intervention is necessary to assess blood glucose levels and provide treatment as needed.
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