HESI RN
HESI RN Exit Exam 2023 Capstone
1. A client is admitted with a severe burn injury. What is the nurse's priority intervention?
- A. Monitor the client's urine output.
- B. Administer intravenous fluids.
- C. Apply cool, moist compresses to the burn area.
- D. Cover the burn area with a sterile dressing.
Correct answer: B
Rationale: The correct answer is B: Administer intravenous fluids. In a client with severe burn injury, the priority intervention is to administer intravenous fluids to prevent shock. Monitoring urine output (Choice A) is important but not the priority. Applying cool, moist compresses (Choice C) can be beneficial but is not the priority over fluid resuscitation. Covering the burn area with a sterile dressing (Choice D) is important for wound care but is not the immediate priority in managing severe burns.
2. When observing a distraught mother scolding her 3-year-old son for wetting his pants in the hallway of a pediatric unit, what initial action should the nurse take?
- A. Suggest that the mother consult a pediatric nephrologist.
- B. Provide disposable training pants while calming the mother.
- C. Refer the mother to a community parent education program.
- D. Inform the mother that toilet training is slower for boys.
Correct answer: B
Rationale: In this situation, the nurse's initial action should be to provide disposable training pants to manage the immediate issue of wetting while also calming the mother. This approach addresses the current distressing situation and offers a practical solution to alleviate the mother's concerns.
3. When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following?
- A. Cardiac arrhythmias.
- B. Hypertension.
- C. Seizures.
- D. Hypothermia.
Correct answer: A
Rationale: The correct answer is A: Cardiac arrhythmias. Reperfusion of cardiac tissue following t-PA administration can lead to cardiac arrhythmias, necessitating resuscitation equipment. Hypertension (choice B) is a common side effect of t-PA but is not directly related to reperfusion. Seizures (choice C) and hypothermia (choice D) are not typically associated with reperfusion from t-PA administration.
4. Several clients on a telemetry unit are scheduled for discharge in the morning, but a telemetry-monitored bed is needed immediately. The charge nurse should make arrangements to transfer which client to another medical unit?
- A. Learning to self-administer insulin injections after being diagnosed with diabetes mellitus
- B. Ambulatory following coronary artery bypass graft surgery performed six days ago
- C. Wearing a sling immobilizer following permanent pacemaker insertion earlier that day
- D. Experiencing syncopal episodes resulting from the dehydration caused by severe diarrhea
Correct answer: A
Rationale: The correct answer is A because transferring a stable client who is learning self-care, such as self-administering insulin injections after being diagnosed with diabetes mellitus, provides the needed telemetry-monitored bed without compromising the client's care. Choice B should not be transferred as the client is ambulatory following surgery and does not require telemetry monitoring. Choice C should not be transferred as the client is wearing a sling immobilizer following pacemaker insertion, which requires close monitoring. Choice D should not be transferred as the client is experiencing syncopal episodes due to severe dehydration, necessitating telemetry monitoring for immediate intervention.
5. The nurse is reviewing a client's electrocardiogram and determines the PR interval (PRI) is prolonged. What does this finding indicate?
- A. Initiation of the impulses from a location outside the SA node
- B. Inability of the SA node to initiate an impulse at the normal rate
- C. Increased conduction time from the SA node to the AV junction
- D. Interference with the conduction through one or both ventricles
Correct answer: C
Rationale: When the PR interval is prolonged, it signifies an increased conduction time from the SA node through the AV junction. This finding is characteristic of a first-degree heart block where there is a delay in the electrical conduction at the level of the AV node. Choices A, B, and D are incorrect as they do not accurately reflect the significance of a prolonged PR interval.