HESI RN
HESI Exit Exam RN Capstone Questions
Question 1 of 5
A client with multiple sclerosis is admitted with an acute exacerbation. What is the nurse's priority action?
Correct Answer: C
Rationale: The correct answer is C. Administering prescribed corticosteroids to reduce inflammation is the priority action when a client with multiple sclerosis is admitted with an acute exacerbation. Corticosteroids help manage symptoms during exacerbations and reduce inflammation. Monitoring vital signs and assessing muscle strength are important aspects of care but not the priority during an acute exacerbation. Educating the client on managing fatigue and preventing relapses is essential but can be addressed after the acute exacerbation has been managed.
Question 2 of 5
A client tells the nurse, 'I have something very important to tell you if you promise not to tell.' The best response by the nurse is
Correct Answer: B
Rationale: The correct answer is B because the nurse cannot promise confidentiality in this context. It is essential to prioritize the safety and well-being of the client and others. Certain information, such as harm to oneself or others, must be reported to ensure appropriate interventions are taken. Choice A is incorrect because while documentation is important, confidentiality cannot be guaranteed in this situation. Choice C is incorrect as the nurse should not make promises that may conflict with their professional responsibilities. Choice D is incorrect as reporting everything to the treatment team without discretion may breach client confidentiality.
Question 3 of 5
A client presents with three positive responses to the CAGE questionnaire. What interpretation should the nurse provide?
Correct Answer: B
Rationale: Two positive responses on the CAGE questionnaire strongly suggest alcohol dependence. Choice A is incorrect as the CAGE questionnaire specifically targets alcohol abuse. Choice C is incorrect because one positive response is not enough to indicate alcohol addiction. Choice D is incorrect because alcohol dependence can be suggested with two positive responses, not all four.
Question 4 of 5
An older adult client with gastroenteritis has been taking the antidiarrheal diphenoxylate for the past 24 hours. What finding requires the nurse to take further action?
Correct Answer: D
Rationale: The correct answer is D. Assessing skin turgor is crucial as tented skin turgor indicates dehydration, which can be worsened by antidiarrheal medications like diphenoxylate. Providing fluids is essential to address dehydration in this client. Monitoring fluid intake (choice A) is important, but assessing skin turgor takes precedence in this situation. Obtaining a stool sample for testing (choice B) could be necessary for diagnostic purposes but is not the immediate priority. Administering a laxative (choice C) is contraindicated in this case as it can worsen the client's condition by further exacerbating fluid loss.
Question 5 of 5
The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250, and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?
Correct Answer: C
Rationale: A cold, pale lower leg is cause for the most concern as it could indicate compromised blood circulation, potentially leading to serious complications like ischemia or thrombosis. Diminished bowel sounds, loss of appetite, and tachypnea are not directly related to the client's condition in atrial fibrillation and the heart rate discrepancy.
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