HESI RN
HESI RN Exit Exam Capstone Questions
Question 1 of 5
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement?
Correct Answer: B
Rationale: The pillows along the side rails do not provide sufficient protection in the event of a seizure. The nurse should inform the UAP to remove the pillows and ensure proper padding of the side rails. This prevents injury, such as hitting the head or limbs during a seizure.
Question 2 of 5
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. Which assessment finding indicates that the client's oxygenation is improving?
Correct Answer: A
Rationale: A pulse oximetry reading of 94% indicates adequate oxygenation. Monitoring oxygen saturation is the most objective way to assess the effectiveness of oxygen therapy.
Question 3 of 5
While assessing a client who is admitted with heart failure and pulmonary edema, the nurse identifies dependent peripheral edema, an irregular heart rate, and a persistent cough that produces pink blood-tinged sputum. After initiating continuous telemetry and positioning the client, which intervention should the nurse implement?
Correct Answer: D
Rationale: The client's cough producing pink, frothy sputum is indicative of pulmonary edema, which needs immediate treatment. Obtaining a sputum sample helps identify any infection that may be contributing to the pulmonary issues. Administering diuretics and notifying the provider are also important, but sputum analysis will guide specific treatment.
Question 4 of 5
After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, 'I have had it with that client. I just can't do anything that pleases him. I'm not going in there again.' The nurse should respond by saying
Correct Answer: C
Rationale: Acknowledging the UAP's feelings while exploring the client's behavior provides a supportive and collaborative approach. This helps maintain a therapeutic environment for both the UAP and the client.
Question 5 of 5
The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take?
Correct Answer: A
Rationale: The infusion should be stopped immediately to prevent further reaction.
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