HESI RN
HESI Exit Exam RN Capstone Questions
Question 1 of 5
A client reports that the skin around the edges of a wound is red and swollen. What is the nurse's priority intervention?
Correct Answer: A
Rationale: The correct answer is to monitor for signs of infection. Redness and swelling around a wound are indicative of a potential infection. The priority intervention for the nurse is to closely monitor the wound for further signs of infection, such as increased drainage or fever. Reinforcing the wound dressing may be necessary, but it is not the priority when infection is suspected. Contacting the healthcare provider is important, but the nurse should first assess and monitor the wound to provide comprehensive information when contacting the provider. Applying a warm compress can potentially worsen the infection by promoting bacterial growth, so it is contraindicated in this situation.
Question 2 of 5
A client presents to the clinic with a large abscess on the right thigh. The healthcare provider incises and drains the abscess. Which instruction should the nurse provide to the client upon discharge?
Correct Answer: B
Rationale: After incision and drainage of an abscess, it is crucial to perform daily wound care and dressing changes to prevent infection and promote healing. Avoiding showering until the wound is completely closed (choice A) may not be practical or necessary. Applying heat to the wound (choice C) can increase the risk of infection and delay healing. While taking the prescribed antibiotic (choice D) is important, wound care and dressing changes are more directly related to promoting healing and preventing complications.
Question 3 of 5
A client with cirrhosis is prescribed spironolactone to manage ascites. Which serum laboratory value is most important for the nurse to monitor?
Correct Answer: D
Rationale: The correct answer is D: Potassium. Spironolactone is a potassium-sparing diuretic, which can lead to hyperkalemia. Monitoring potassium levels is crucial to prevent complications like cardiac arrhythmias. Choices A, B, and C are incorrect because sodium, calcium, and magnesium levels are not directly affected by spironolactone use for managing ascites in cirrhosis.
Question 4 of 5
A client with chronic kidney disease has a potassium level of 6.2 mEq/L. Which intervention should the nurse implement?
Correct Answer: C
Rationale: In this scenario, the correct intervention is to administer a potassium-binding medication (Option C). Chronic kidney disease can lead to hyperkalemia, which is characterized by high levels of potassium in the blood. Potassium-binding medications work by binding excess potassium in the gastrointestinal tract, preventing its absorption and aiding in its elimination from the body. Option A is incorrect because encouraging the client to eat foods rich in potassium would exacerbate the hyperkalemia. Option B, administering a potassium-sparing diuretic, is inappropriate because these drugs can actually increase potassium levels. Option D, holding all medications containing potassium, may be necessary but does not directly address the elevated potassium level as effectively as administering a potassium-binding medication. Educationally, it is crucial for nurses to understand the management of electrolyte imbalances in clients with chronic kidney disease. This scenario highlights the importance of selecting the appropriate intervention to address the specific electrolyte abnormality present, emphasizing the need for critical thinking and knowledge of pharmacological interventions in the context of renal dysfunction.
Question 5 of 5
The nurse is providing care for a client with advanced liver disease who is experiencing ascites. Which intervention should the nurse implement to help manage the client's fluid volume?
Correct Answer: D
Rationale: Administering a diuretic as prescribed is the most appropriate intervention to manage fluid volume in a client with ascites due to advanced liver disease. Diuretics help reduce fluid accumulation in the body, including the abdominal cavity where ascites occurs. Increasing sodium intake would worsen fluid retention, and encouraging more fluid intake can exacerbate ascites. Placing the client in a supine position does not directly address the fluid volume issue associated with ascites.