HESI RN Exit Exam Capstone

Questions 101

HESI RN

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HESI RN Exit Exam Capstone Questions

Question 1 of 5

The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal

Correct Answer: A

Rationale: An S3 ventricular gallop is typically heard in clients with congestive heart failure due to fluid overload.

Question 2 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 3 of 5

A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care?

Correct Answer: B

Rationale: Leukopenia, or a low white blood cell count, is a critical concern in clients undergoing radiation therapy due to increased risk of infection.

Question 4 of 5

A young adult visits the clinic reporting symptoms associated with gastritis. Which information in the client's history is most important for the nurse to address in the teaching plan?

Correct Answer: B

Rationale: Excessive alcohol consumption is a major risk factor for gastritis and should be prioritized in the teaching plan. Although NSAIDs and spicy foods can contribute to gastritis, alcohol is the most significant factor requiring immediate lifestyle changes.

Question 5 of 5

The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who has been experiencing increasing shortness of breath. Which finding requires immediate intervention?

Correct Answer: D

Rationale: A pulse oximetry reading of 88% indicates hypoxemia, which requires immediate intervention to improve oxygenation. The use of accessory muscles and a barrel chest appearance are common in COPD but do not require urgent intervention.

Similar Questions

The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who has been experiencing increasing shortness of breath. Which finding requires immediate intervention?
A client with adrenal insufficiency is admitted to the ICU with acute adrenal crisis. The client's vital signs include heart rate 138 bpm and BP 80/60. What is the nurse's first intervention?
A client with COPD and a history of emphysema presents with increasing shortness of breath. What action should the nurse implement first?
A client is suspected of having a stroke. What is the nurse's priority action?
A client is admitted with pneumonia and is started on antibiotics. After 3 days, the client reports difficulty breathing and a rash. What is the nurse's first action?

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