HESI RN
HESI Exit Exam RN Capstone
1. A client in heart failure (HF) presents with weakness and poor urine output. Which assessment finding requires immediate action?
- A. Heart rate of 122 bpm and respiratory rate of 28.
- B. Yellow sputum expectorated.
- C. Temperature of 100.5°F (38.1°C).
- D. Shortness of breath on exertion.
Correct answer: C
Rationale: An elevated temperature may indicate infection and should be treated immediately in a client with heart failure.
2. An adolescent female who is leaning forward with her hands on her knees to breathe tells the practical nurse that she has been using triamcinolone (Azmacort) inhalation aerosol before coming to the clinic. Which action should the PN implement?
- A. Obtain vital signs and assess breath sounds for wheezing.
- B. Collect a blood sample for white blood cell count.
- C. Give the client a nebulizer breathing treatment.
- D. Administer another dose of Azmacort.
Correct answer: A
Rationale: When a patient presents with breathing difficulties, the first action should be to assess vital signs and breath sounds to evaluate the severity of the condition. This assessment will provide crucial information to determine the appropriate course of action and treatment. Collecting a blood sample for a white blood cell count, giving a nebulizer treatment, or administering another dose of Azmacort would not be the initial priority in this situation. Therefore, option A is the correct choice as it focuses on assessing the patient's respiratory status to guide further interventions.
3. The client states, “It seems strange that I don’t have a TV in my room.” Which statement would be best for the nurse to provide?
- A. You can watch TV as much as you want outside of your room.
- B. Sometimes clients feel like the TV is sending them messages.
- C. It’s important to be out of your room and talking to others.
- D. Watching TV is a passive activity and we want you to be active.
Correct answer: B
Rationale: The correct answer is B because clients with depression or psychosis may interpret TV as sending messages, so it is often removed to prevent this risk. Choice A is incorrect because it does not address the client's concern and may not be feasible. Choice C is incorrect because it diverts from the client's immediate issue regarding the TV. Choice D is incorrect because it does not address the client's specific concern and instead focuses on the activity level.
4. An agitated, confused female client arrives in the emergency department. Her history includes type 1 diabetes mellitus, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting:
- A. 2 to 5 g of a simple carbohydrate.
- B. 10 to 15 g of a simple carbohydrate.
- C. 18 to 20 g of a simple carbohydrate.
- D. 25 to 30 g of a simple carbohydrate.
Correct answer: B
Rationale: The correct answer is B: 10 to 15 g of a simple carbohydrate. In the treatment of hypoglycemia, it is important to administer a specific amount of simple carbohydrates to raise blood glucose levels effectively without causing hyperglycemia. 10 to 15 g of simple carbohydrates, such as glucose tablets, fruit juice, or regular soft drinks, is recommended to rapidly increase blood sugar levels in clients experiencing hypoglycemia. Choices A, C, and D are incorrect as they either provide too little or too much glucose, which may not effectively treat the hypoglycemic episode or may lead to rebound hyperglycemia.
5. A client with a history of chronic kidney disease (CKD) is receiving erythropoietin therapy. Which assessment finding is most concerning?
- A. Increased fatigue
- B. Headache
- C. Elevated blood pressure
- D. Low urine output
Correct answer: C
Rationale: In a client with chronic kidney disease receiving erythropoietin therapy, elevated blood pressure is the most concerning assessment finding. Erythropoietin can increase red blood cell production, leading to thicker blood, which in turn can elevate blood pressure. Elevated blood pressure in this scenario may indicate worsening hypertension, which requires prompt intervention to prevent complications such as stroke, heart attack, or further kidney damage. Increased fatigue (choice A) is a common symptom in CKD patients and can be expected with erythropoietin therapy. Headache (choice B) can occur but is less concerning than elevated blood pressure in this context. Low urine output (choice D) is a significant finding in CKD, but in a client receiving erythropoietin, elevated blood pressure takes precedence due to its potential for immediate adverse effects.