HESI RN
RN HESI Exit Exam Capstone Questions
Question 1 of 9
A client is receiving continuous intravenous heparin for a deep vein thrombosis. Which laboratory result should the nurse monitor to ensure therapeutic heparin levels?
Correct Answer: B
Rationale: The activated partial thromboplastin time (aPTT) is the most accurate measure of heparin's therapeutic effect. Heparin increases the time it takes for blood to clot, and the aPTT helps determine whether the dose is within the desired range for anticoagulation therapy. Monitoring the INR, hemoglobin, or platelet count is not specific to assessing therapeutic heparin levels and may not reflect the anticoagulant effect of heparin.
Question 2 of 9
A client with hypothyroidism is prescribed levothyroxine. What should the nurse include in the teaching plan about this medication?
Correct Answer: B
Rationale: The correct answer is B: 'Take the medication on an empty stomach.' Levothyroxine should be taken on an empty stomach to enhance absorption and effectiveness. The medication is typically taken in the morning before breakfast. Choice A is incorrect because taking levothyroxine with a full meal can decrease its absorption. Choice C is incorrect because bedtime dosing may lead to insomnia. Choice D is incorrect because levothyroxine is a daily medication for hypothyroidism, not to be taken as needed for symptoms.
Question 3 of 9
A young male client with an above-knee amputation (AKA) reports that his 'right foot is aching.' What is the most important intervention for the nurse to implement?
Correct Answer: B
Rationale: The correct answer is B because gabapentin is prescribed to treat phantom limb pain, which is common in individuals with amputations. Option A is not the most important intervention at this time since the client is reporting physical pain, not emotional distress. Option C is not appropriate because the client is reporting aching in the foot, not the stump. Option D does not address the underlying issue of phantom limb pain that needs to be managed.
Question 4 of 9
Which statement made by the client indicates an understanding of the instructions regarding the administration of alendronate (Fosamax)?
Correct Answer: B
Rationale: The correct answer is B. Alendronate (Fosamax) should be taken with a full glass of water in the morning to prevent esophageal irritation and ensure proper absorption. Choice A is incorrect because taking alendronate at bedtime increases the risk of esophageal irritation due to lying down. Choice C is incorrect because patients should remain upright for at least 30 minutes after taking alendronate to prevent esophageal irritation. Choice D is incorrect because alendronate should be taken on an empty stomach, not with food, to enhance absorption.
Question 5 of 9
A mother reports that she has been applying triple antibiotic ointment for her son's athlete's foot for two days with no improvement. What should the nurse instruct?
Correct Answer: B
Rationale: Antibiotic ointment is ineffective against athlete's foot, which is a fungal infection. The nurse should instruct the mother to stop using the ointment and ensure the feet are dried properly, as moisture exacerbates fungal infections. Applying a different antifungal medication is a valid option, but addressing the moisture issue by drying the feet completely is the immediate priority. Continuing to use the antibiotic ointment or reapplying it for a longer period will not treat the fungal infection effectively.
Question 6 of 9
The nurse is preparing a discharge teaching plan for a liver transplant client. Which instruction is most important to include in this plan?
Correct Answer: B
Rationale: The most critical instruction to include in the discharge teaching plan for a liver transplant client is to take immunosuppressant medications as prescribed. This is vital to prevent organ rejection and ensure the success of the transplant. While ensuring daily follow-up with the healthcare provider is important for monitoring progress, avoiding crowds for the first two months after surgery helps reduce the risk of infections but is not as crucial as medication adherence. Returning to work in three months is a consideration but not the most important aspect immediately post-transplant.
Question 7 of 9
While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse¢â‚¬â„¢s best response?
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 8 of 9
A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)?
Correct Answer: D
Rationale: Performing nostril and mouth care is a non-invasive task that can be safely delegated to an unlicensed assistive personnel (UAP). Observing the type and amount of nasogastric tube drainage requires assessment skills and understanding of potential complications, making it more appropriate for a licensed healthcare professional. Monitoring the client for nausea or other complications involves interpreting client responses and identifying adverse reactions, which also requires a licensed healthcare professional. Irrigating the nasogastric tube with the ordered solution involves a procedure that can impact the client's condition and should be performed by a licensed healthcare professional to prevent complications.
Question 9 of 9
A client is experiencing shortness of breath and wheezing. What is the nurse's first action?
Correct Answer: A
Rationale: Administering a bronchodilator is the priority intervention to open the airways and relieve wheezing and shortness of breath. Bronchodilators work quickly to dilate the airways, making it easier for the client to breathe. Checking oxygen saturation is important but can be done after initiating bronchodilator therapy. Encouraging pursed-lip breathing and elevating the head of the bed can help improve breathing patterns but should follow the administration of the bronchodilator.