HESI RN
RN HESI Exit Exam Capstone
1. A young adult was hit in the temporal area with a baseball bat and is being monitored for signs of a closed head injury. Which finding indicates a developing epidural hematoma?
- A. Nausea and vomiting.
- B. Altered consciousness within the first 24 hours after injury.
- C. Severe headache and blurred vision.
- D. Loss of motor function on the affected side.
Correct answer: B
Rationale: The correct answer is B. Altered consciousness within the first 24 hours after a temporal injury is a classic sign of epidural hematoma, which is a neurosurgical emergency. This finding occurs due to the rapid expansion of the hematoma, causing compression of the brain. Nausea and vomiting (choice A) are more commonly associated with other types of head injuries, such as concussion. Severe headache and blurred vision (choice C) are symptoms seen in various head injuries but are not specific to epidural hematomas. Loss of motor function on the affected side (choice D) is more indicative of a different type of head injury, such as a contusion or intracerebral hematoma.
2. The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement?
- A. Encourage the client to drink more slowly
- B. Stop feeding and assess for signs of aspiration
- C. Elevate the head of the bed further
- D. Teach coughing and deep breathing exercises
Correct answer: B
Rationale: When an older adult with aspiration pneumonia coughs while attempting to drink, it may indicate aspiration. Aspiration can lead to serious complications. Therefore, the appropriate intervention for the nurse in this situation is to stop feeding immediately and assess the client for signs of aspiration. Encouraging the client to drink more slowly (Choice A) may not address the risk of aspiration. Elevating the head of the bed further (Choice C) is generally beneficial to prevent aspiration but is not the priority when immediate assessment is needed. Teaching coughing and deep breathing exercises (Choice D) is not appropriate when the client is actively coughing during feeding and requires immediate assessment for potential aspiration.
3. A client who had a subtotal parathyroidectomy two days ago is now preparing for discharge. Which assessment finding requires immediate provider notification?
- A. Afebrile with a normal pulse.
- B. No bowel movement since surgery.
- C. No appetite for breakfast.
- D. A positive Chvostek's sign.
Correct answer: D
Rationale: A positive Chvostek's sign suggests hypocalcemia, which is a post-parathyroidectomy complication and requires prompt treatment. The other options are less urgent: being afebrile with a normal pulse is expected, no bowel movement since surgery can be managed with interventions like early ambulation and stool softeners, and no appetite for breakfast is common postoperatively and can be addressed without immediate provider notification.
4. A client with hypertension is prescribed a low-sodium diet. What is the most important instruction for the nurse to provide?
- A. Limit sodium intake to 2 grams per day.
- B. Choose fresh fruits and vegetables.
- C. Drink at least 8 glasses of water daily.
- D. Avoid processed foods and canned soups.
Correct answer: D
Rationale: The correct answer is D. Avoiding processed foods and canned soups is crucial for a client with hypertension on a low-sodium diet because these foods are typically high in sodium content. Fresh fruits and vegetables are generally healthy choices but may still contain some natural sodium. While limiting sodium intake to 2 grams per day is important, specifically avoiding processed foods and canned soups is more critical in this situation. Drinking water is essential for overall health but is not the most important instruction when focusing on reducing sodium intake.
5. A client receiving total parenteral nutrition (TPN) is experiencing nausea and vomiting. What is the nurse's first action?
- A. Check the client's blood glucose level.
- B. Decrease the rate of TPN infusion.
- C. Administer an antiemetic as prescribed.
- D. Check the client's TPN bag for solution accuracy.
Correct answer: D
Rationale: The correct first action for the nurse to take when a client receiving TPN is experiencing nausea and vomiting is to check the client's TPN bag for solution accuracy. This is crucial to ensure that the correct solution is being administered and to address any potential errors. Checking the blood glucose level or administering an antiemetic may be necessary interventions but addressing the TPN bag's accuracy should be the priority to prevent any complications related to incorrect TPN solution.
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