HESI RN Exit Exam Capstone

Questions 101

HESI RN

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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

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 3 of 5

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?

Correct Answer: B

Rationale: An IV fluid bolus stabilizes blood pressure during adrenal crisis.

Question 4 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 5 of 5

A client with a seizure disorder is prescribed phenytoin. What is the most important teaching the nurse should provide?

Correct Answer: B

Rationale: Phenytoin should be taken consistently, as missing doses can increase the risk of seizures. Additionally, clients should be aware of drug interactions, such as with antacids, which can reduce the absorption of phenytoin.

Similar Questions

A client with a seizure disorder is prescribed phenytoin. What is the most important teaching the nurse should provide?
The nurse is providing care for a client with schizophrenia who receives haloperidol decanoate 75 mg IM every 4 weeks. The client begins developing a puckering and smacking of the lips and facial grimacing. Which intervention should the nurse implement?
A 48 year-old client with chronic alcoholism is admitted to the hospital. The nurse would anticipate that the client may be deficient in which vitamins?
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?
The nurse is caring for a client post-surgery with an order to ambulate the client every 2 hours. Which of the following tasks could be safely delegated to an unlicensed assistive personnel (UAP)?

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