RN HESI Exit Exam Capstone

Questions 79

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RN HESI Exit Exam Capstone Questions

Question 1 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.

Question 2 of 5

While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse�€™s best response?

Correct Answer: C

Rationale: Diuretics must be continued as long as the fluid problem persists to prevent heart failure symptoms.

Question 3 of 5

A client with chronic kidney disease is admitted with complaints of fatigue and swelling in the lower extremities. What laboratory finding is most important for the nurse to report?

Correct Answer: B

Rationale: The correct answer is B. A hemoglobin level of 8 g/dL suggests anemia, which commonly occurs in clients with chronic kidney disease and requires prompt intervention. Reporting this finding is crucial to address the anemic condition. Choices A, C, and D are important in the context of chronic kidney disease but do not directly relate to the symptoms of fatigue and swelling in the lower extremities described in the scenario.

Question 4 of 5

A client who had a subtotal parathyroidectomy two days ago is now preparing for discharge. Which assessment finding requires immediate provider notification?

Correct Answer: D

Rationale: A positive Chvostek's sign suggests hypocalcemia, which is a post-parathyroidectomy complication and requires prompt treatment. The other options are less urgent: being afebrile with a normal pulse is expected, no bowel movement since surgery can be managed with interventions like early ambulation and stool softeners, and no appetite for breakfast is common postoperatively and can be addressed without immediate provider notification.

Question 5 of 5

In assessing a client with type 1 diabetes mellitus, the nurse notes that the client's respirations have changed from 16 breaths/min with a normal depth to 32 breaths/min and deep, and the client becomes lethargic. Which assessment data should the nurse obtain next?

Correct Answer: B

Rationale: Deep, rapid respirations (Kussmaul respirations) and lethargy are signs of diabetic ketoacidosis (DKA), which occurs in uncontrolled type 1 diabetes. Checking the blood glucose is the priority to confirm hyperglycemia and guide immediate treatment. Pulse oximetry is not the priority in this situation as the issue is related to altered glucose levels, not oxygenation. Arterial blood gases and serum electrolytes may be important later in the management of DKA but are not the initial priority compared to confirming and addressing the hyperglycemia.

Similar Questions

In assessing a client with type 1 diabetes mellitus, the nurse notes that the client's respirations have changed from 16 breaths/min with a normal depth to 32 breaths/min and deep, and the client becomes lethargic. Which assessment data should the nurse obtain next?
A client with peripheral vascular disease reports leg pain while walking. What intervention is most effective for the nurse to recommend?
A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge?
The nurse is caring for a group of clients with the help of a PN. Which nursing actions should the nurse assign to the PN?
Prior to administering warfarin to a client with a history of atrial fibrillation, what lab result should the nurse review?

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