HESI RN
HESI RN Exit Exam 2024 Capstone Questions
Question 1 of 5
A client with a history of stroke is receiving warfarin. What is the nurse's priority assessment?
Correct Answer: B
Rationale: The correct answer is to assess for signs of bleeding. Warfarin is an anticoagulant that increases the risk of bleeding in patients. Monitoring for signs of bleeding such as easy bruising, petechiae, blood in urine or stool, or unusual bleeding from gums is crucial. Checking the client's blood pressure (choice A) is important but not the priority in this situation. Assessing the client's neurological status (choice C) is essential in stroke patients but is not the priority related to warfarin therapy. Monitoring intake and output (choice D) is important for overall assessment but is not the priority when a client is on warfarin, as assessing for bleeding takes precedence.
Question 2 of 5
The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective and must be reported by the nurse immediately to the healthcare provider?
Correct Answer: B
Rationale: A fever of 103 degrees Fahrenheit indicates that the infection is not under control despite antibiotic therapy. Fever is a common sign of ongoing infection or inadequate response to treatment. Nausea and vomiting, diffuse macular rash, and muscle tenderness are not typically indicative of the effectiveness of antibiotic therapy in treating infective endocarditis.
Question 3 of 5
The nurse assesses a 72-year-old client who was admitted for right-sided congestive heart failure. Which of the following would the nurse anticipate finding?
Correct Answer: B
Rationale: Correct! In right-sided congestive heart failure, jugular vein distention is a common finding due to the backup of blood in the systemic circulation. This results in increased venous pressure, leading to jugular vein distention. Choices A, C, and D are incorrect because decreased urinary output, pleural effusion, and bibasilar crackles are more commonly associated with other conditions such as kidney dysfunction, lung issues, and pulmonary edema.
Question 4 of 5
The client is being taught to choose foods rich in potassium to prevent digitalis toxicity. Which choice indicates the client understands dietary needs?
Correct Answer: D
Rationale: The correct answer is D: Baked potato. Baked potatoes are rich in potassium, which is essential in preventing digitalis toxicity by helping to maintain normal electrolyte levels. Apricots, bananas, and oranges are also sources of potassium, but a baked potato has a higher potassium content compared to the other options, making it a more effective choice for preventing digitalis toxicity.
Question 5 of 5
The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to
Correct Answer: A
Rationale: Weight-bearing exercises are crucial in managing osteoporosis as they help strengthen bones. Choice A is the correct answer because weight-bearing activities, such as walking, dancing, or weight training, help stimulate bone formation and strengthen bones, which is essential in managing osteoporosis. Choice B is incorrect as the primary focus should be on the type of exercise rather than weight reduction. Choice C is incorrect because avoiding exercise altogether can lead to further bone density loss, and it is important to engage in safe weight-bearing activities. Choice D is incorrect as the primary goal of exercise in osteoporosis is to improve bone density through weight-bearing activities.