HESI RN
HESI RN Exit Exam Capstone Questions
Question 1 of 5
A client with a myocardial infarction is prescribed nitroglycerin. What instruction should the nurse include?
Correct Answer: D
Rationale: Clients prescribed nitroglycerin should be instructed to limit its use to no more than three doses in 15 minutes. This prevents excessive use, which can lead to severe hypotension and other complications.
Question 2 of 5
The nurse is providing care for a client with schizophrenia who receives haloperidol decanoate 75 mg IM every 4 weeks. The client begins developing a puckering and smacking of the lips and facial grimacing. Which intervention should the nurse implement?
Correct Answer: C
Rationale: These symptoms are characteristic of tardive dyskinesia, a side effect of long-term antipsychotic use. The nurse should assess the severity of these movements using the AIMS scale and report to the healthcare provider for further management.
Question 3 of 5
A client reports unilateral leg swelling after a long flight. What complication is the nurse most concerned about?
Correct Answer: A
Rationale: Unilateral leg swelling following a long flight may indicate a pulmonary embolism, which is a life-threatening complication requiring immediate attention.
Question 4 of 5
While changing a client's chest tube dressing, the nurse notes a cracking sensation when gentle pressure is applied to the skin at the insertion site. What should the nurse do next?
Correct Answer: D
Rationale: Measuring the area of swelling and crackling helps monitor subcutaneous emphysema progression.
Question 5 of 5
A client receiving total parenteral nutrition (TPN) reports nausea and dizziness. What action should the nurse take first?
Correct Answer: B
Rationale: Checking vital signs and blood pressure helps assess the client's stability when reporting symptoms like nausea and dizziness during TPN.
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