HESI RN
RN HESI Exit Exam Capstone Questions
Question 1 of 5
A client with deep vein thrombosis (DVT) is prescribed anticoagulants. What should the nurse monitor closely?
Correct Answer: D
Rationale: In clients with DVT, assessing for pulmonary embolism is crucial as a clot in the lungs can be life-threatening. Sudden shortness of breath or chest pain are key signs of a pulmonary embolism. While monitoring for signs of bleeding is important due to anticoagulant therapy, the immediate concern is detecting a potential pulmonary embolism. Monitoring vital signs and pain in the affected limb are relevant aspects of care but are not as urgent as assessing for pulmonary embolism in this scenario.
Question 2 of 5
The home care nurse visits a client who has cancer. The client reports having a good appetite but experiencing nausea when smelling food cooking. Which action should the nurse implement?
Correct Answer: A
Rationale: In some cases, the smell of food cooking can trigger nausea in cancer patients. Cooking food outside reduces the intensity of odors that could trigger nausea, helping the client maintain adequate nutrition. Providing anti-nausea medication (Choice B) may not address the root cause of the nausea triggered by the smell of cooking food. Suggesting cold water (Choice C) or smaller, frequent meals (Choice D) may not directly address the issue of cooking odors triggering nausea, which is specific to this client's situation.
Question 3 of 5
A client reports dizziness when standing up quickly. What advice should the nurse give?
Correct Answer: B
Rationale: The correct advice for a client experiencing dizziness when standing up quickly is to change positions slowly to prevent dizziness. This symptom is suggestive of postural hypotension, where a sudden change in position can lead to a drop in blood pressure, causing dizziness. Encouraging the client to drink more fluids (Choice A) may be beneficial for other conditions but is not directly related to the prevention of dizziness in this case. Reporting the symptom to the healthcare provider immediately (Choice C) is important if the dizziness is persistent or severe, but the immediate action to prevent it is to change positions slowly. Limiting physical activity (Choice D) may not necessarily address the underlying cause of dizziness in this context.
Question 4 of 5
A client with pneumonia is receiving oxygen therapy. What assessment finding requires immediate intervention?
Correct Answer: B
Rationale: The correct answer is B. An oxygen saturation of 89% indicates hypoxemia, which is below the normal range (usually 95-100%). This finding requires immediate intervention as it signifies inadequate oxygenation. Options A, C, and D are within normal limits and do not indicate an urgent need for intervention. Option A indicates a good oxygen saturation level, option C denotes a normal respiratory rate, and option D suggests a normal heart rate. Therefore, these options do not require immediate intervention compared to the critically low oxygen saturation level of 89% in option B.
Question 5 of 5
A young adult was hit in the temporal area with a baseball bat and is being monitored for signs of a closed head injury. Which finding indicates a developing epidural hematoma?
Correct Answer: B
Rationale: The correct answer is B. Altered consciousness within the first 24 hours after a temporal injury is a classic sign of epidural hematoma, which is a neurosurgical emergency. This finding occurs due to the rapid expansion of the hematoma, causing compression of the brain. Nausea and vomiting (choice A) are more commonly associated with other types of head injuries, such as concussion. Severe headache and blurred vision (choice C) are symptoms seen in various head injuries but are not specific to epidural hematomas. Loss of motor function on the affected side (choice D) is more indicative of a different type of head injury, such as a contusion or intracerebral hematoma.
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