HESI RN
HESI RN Exit Exam Capstone Questions
Question 1 of 5
Which intervention should the nurse include in the care plan for a child with tetanus?
Correct Answer: D
Rationale: Tetanus causes severe muscle spasms and sensitivity to stimuli, so minimizing stimuli like light, sound, and touch can help prevent painful spasms. Monitoring vital signs and administering antibiotics are important but managing stimuli is crucial for the child's comfort and safety.
Question 2 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 3 of 5
A client with atrial fibrillation is prescribed warfarin, and their INR is elevated. What is the nurse's priority action?
Correct Answer: D
Rationale: An elevated INR in clients taking warfarin increases the risk of bleeding. The nurse should notify the healthcare provider immediately and hold the next dose of warfarin to prevent complications.
Question 4 of 5
The nurse is caring for a preterm newborn with nasal flaring, grunting, and sternal retractions. After administering surfactant, which assessment is most important for the nurse to monitor?
Correct Answer: C
Rationale: Surfactant therapy is used to improve lung function and gas exchange in premature infants with respiratory distress. Monitoring arterial blood gases is essential to assess the effectiveness of the treatment and ensure adequate oxygenation.
Question 5 of 5
A client with Alzheimer's disease is prescribed donepezil. What is the most important teaching point?
Correct Answer: C
Rationale: Donepezil helps improve cognitive function but is not a cure for Alzheimer's disease.
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