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 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

An older client is admitted to the intensive care unit unconscious after several days of vomiting and diarrhea. The nurse inserts a urinary catheter and observes dark amber urine output. Which intervention should the nurse implement first?

Correct Answer: C

Rationale: A fluid bolus is the first step in stabilizing a client with hypovolemic symptoms.

Question 3 of 5

A client with deep vein thrombosis (DVT) is prescribed warfarin. What lab value should the nurse review before administering the medication?

Correct Answer: C

Rationale: INR should be reviewed before administering warfarin to ensure the client is within the therapeutic range.

Question 4 of 5

The nurse is caring for a client with a suspected myocardial infarction (MI). Which laboratory test result is most indicative of a recent MI?

Correct Answer: A

Rationale: Elevated troponin levels are the most specific and sensitive indicator of myocardial infarction. Troponin levels increase within hours of an MI and remain elevated for several days.

Question 5 of 5

At 0600 while admitting a woman for a scheduled repeat cesarean section, the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

Correct Answer: B

Rationale: Drinking liquids before surgery can increase the risk of aspiration during anesthesia. Therefore, the anesthesia care provider must be informed immediately to determine how to proceed, as this could delay or alter the surgical plan.

Similar Questions

At 0600 while admitting a woman for a scheduled repeat cesarean section, the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?
A client with hyperthyroidism is admitted for total thyroidectomy. What is the nurse's priority post-operative intervention?
The nurse is teaching a client about postoperative care following a total knee arthroplasty. What instruction should the nurse prioritize?
A postoperative client with a history of diabetes mellitus is showing signs of hyperglycemia. What should the nurse assess first?
The nurse is caring for a client with acute pancreatitis who is reporting severe abdominal pain. Which nursing intervention should the nurse implement first?

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