HESI RN
HESI RN Exit Exam Capstone Questions
Question 1 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 2 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 3 of 5
A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the therapeutic response, which assessment should the nurse obtain?
Correct Answer: D
Rationale: Lactulose is used to reduce ammonia levels, so consciousness is an indicator of efficacy.
Question 4 of 5
A client is admitted to the emergency department after a motor vehicle accident. The client has a Glasgow Coma Scale (GCS) score of 10. What does this score indicate?
Correct Answer: B
Rationale: A Glasgow Coma Scale score of 10 falls into the range of moderate impairment, indicating the need for further assessment and monitoring.
Question 5 of 5
A client reports unilateral leg swelling after a long flight. What complication is the nurse most concerned about?
Correct Answer: A
Rationale: Unilateral leg swelling following a long flight may indicate a pulmonary embolism, which is a life-threatening complication requiring immediate attention.
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