HESI RN
HESI RN Exit Exam 2024 Capstone Questions
Question 1 of 5
A client receiving IV heparin reports tarry stools and abdominal pain. What interventions should the nurse implement?
Correct Answer: D
Rationale: The correct intervention for the client receiving IV heparin who reports tarry stools and abdominal pain is to monitor the stool for the presence of blood. This is crucial to assess for gastrointestinal bleeding, a potential complication of heparin therapy. Assessing the characteristics of the client's pain may be helpful but is not the priority when signs of GI bleeding are present. Administering warfarin is not appropriate without a thorough assessment and confirmation of the cause of symptoms. While obtaining recent partial thromboplastin time results is important in monitoring heparin therapy, in this scenario, the immediate concern is to assess for possible GI bleeding.
Question 2 of 5
A client presents to the labor and delivery unit with a report of leaking fluid that is greenish-brown vaginal discharge. Which action should the nurse take first?
Correct Answer: B
Rationale: Greenish-brown discharge likely indicates meconium in the amniotic fluid, which poses a risk to the fetus. Continuous fetal monitoring should be initiated immediately to assess for signs of fetal distress. Meconium-stained amniotic fluid can lead to meconium aspiration syndrome in the newborn, so timely monitoring is crucial. Checking the amniotic fluid pH can help confirm the presence of meconium but is not the priority over fetal monitoring. Assessing maternal vital signs is important but secondary to monitoring the fetal well-being in this urgent situation. Notifying the healthcare provider can follow once the immediate fetal assessment is underway.
Question 3 of 5
A client with anemia is prescribed iron supplements. What teaching should the nurse provide?
Correct Answer: D
Rationale: The correct answer is D: Take iron supplements with vitamin C to improve absorption. Vitamin C enhances iron uptake, making it more bioavailable for the body. It is essential to avoid taking iron supplements with milk (choice
B) as calcium-rich foods can hinder iron absorption. Taking iron supplements with meals (choice
A) can help reduce stomach upset, but the optimal way to enhance absorption is with vitamin C. Black, tarry stools (choice
C) are not a typical side effect of iron supplements and should be reported to the healthcare provider.
Question 4 of 5
A child is admitted with bacterial meningitis. What assessment finding should the nurse monitor most closely?
Correct Answer: B
Rationale:
Correct Answer: B. Signs of increased intracranial pressure, such as changes in consciousness or pupil reactivity, are critical to monitor in children with bacterial meningitis to prevent complications. Monitoring the client's skin for rash and lesions (
Choice
A) is not the priority in bacterial meningitis. While monitoring blood pressure (
Choice
C) is important, signs of increased intracranial pressure take precedence. Monitoring for changes in heart rate and rhythm (
Choice
D) is less specific to the condition and may not indicate worsening neurological status.
Question 5 of 5
The nurse is providing discharge instructions to a client with chronic venous insufficiency. Which recommendation should the nurse include to help prevent complications?
Correct Answer: B
Rationale: The correct recommendation for a client with chronic venous insufficiency to prevent complications is to wear compression stockings. Compression stockings help improve venous circulation and prevent the worsening of symptoms. While elevating the legs is also beneficial, the priority intervention in preventing complications is wearing compression stockings. Using a heating pad on the legs can actually worsen the condition by dilating blood vessels, and massaging the legs daily can potentially damage fragile skin in clients with chronic venous insufficiency.