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: In the context of a client with a myocardial infarction prescribed nitroglycerin, the correct instruction for the nurse to provide is option D: "Limit nitroglycerin use to no more than three doses in 15 minutes." This instruction is crucial because nitroglycerin is a potent vasodilator that can cause a rapid drop in blood pressure. Taking excessive doses in a short period can lead to hypotension, which can be dangerous for the client. Option A is incorrect because nitroglycerin is not meant to be taken only during severe chest pain; it is also used prophylactically to prevent angina episodes. Option B is incorrect as nitroglycerin should be stored in its original container to maintain its potency, not in a dark container to protect it from light. Option C is incorrect because nitroglycerin is typically taken at the onset of chest pain, not necessarily before engaging in physical activity. Educationally, understanding the appropriate use of nitroglycerin is vital for nursing practice, especially in caring for clients with cardiac conditions. Nurses must ensure that clients are educated on the correct administration, dosage, and timing of nitroglycerin to promote optimal therapeutic effects and prevent potential complications.
Question 2 of 5
A teenager presents to the emergency department with palpitations after vaping at a party. The client is anxious, fearful, and hyperventilating. Which acid-base imbalance does the nurse anticipate the client developing?
Correct Answer: B
Rationale: Hyperventilation from anxiety or fear causes an excessive loss of CO2, leading to respiratory alkalosis. This shift in pH results from the rapid, shallow breathing that reduces the level of carbon dioxide in the blood. Respiratory acidosis would occur in cases of poor ventilation or CO2 retention, while metabolic acidosis/alkalosis relates to disturbances in bicarbonate, not breathing patterns.
Question 3 of 5
Which intervention should the nurse include in the care plan for a child with tetanus?
Correct Answer: D
Rationale: In caring for a child with tetanus, the nurse should include minimizing the amount of stimuli in the room as an essential intervention. Tetanus, also known as lockjaw, is a condition caused by the toxin produced by the bacteria Clostridium tetani. This toxin affects the nervous system, leading to muscle stiffness and spasms. Minimizing stimuli in the room, such as noise and bright lights, can help reduce the frequency and severity of muscle spasms, which are characteristic of tetanus. Option A, ensuring proper hydration, is important for overall health but does not directly address the symptoms of tetanus. Administering prescribed antibiotics (Option B) is not the primary treatment for tetanus; instead, tetanus immune globulin is typically used. While monitoring vital signs (Option C) is important in any patient care setting, it is not the most critical intervention for managing tetanus in this scenario. Educationally, understanding the rationale behind each intervention helps nurses prioritize and provide appropriate care for patients with tetanus. By selecting the correct intervention, nurses can effectively manage the symptoms of tetanus and promote better outcomes for the child. This question highlights the importance of tailored interventions based on the specific needs of patients with different conditions.
Question 4 of 5
A client scheduled for a bronchoscopy in the morning is anxious and asking the nurse numerous questions about the procedure. Which intervention has the highest priority in preparing the client for the procedure?
Correct Answer: C
Rationale: In preparing a client for a bronchoscopy, the highest priority intervention is option C: Instruct the client to write down the questions. This is essential because it allows the client to organize their thoughts, address their concerns, and feel more empowered and in control of the situation. By writing down questions, the client is more likely to remember them and can effectively communicate with healthcare providers during the pre-procedure preparation. Option A, providing detailed education about the procedure, is important but may not address the immediate anxiety and questions of the client. Option B, administering anti-anxiety medication, should not be the first line of intervention as it does not address the root cause of the anxiety and should only be used if necessary. Option D, reassuring the client about the safety of the procedure, is important but may not directly address the client's immediate concerns and questions. In an educational context, this rationale emphasizes the importance of effective communication and empowering clients to take an active role in their care. Encouraging clients to write down their questions promotes patient-centered care and helps healthcare providers address individual needs and concerns, leading to better outcomes and patient satisfaction.
Question 5 of 5
The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instruction should the nurse provide the UAP who is working with the nurse?
Correct Answer: D
Rationale: The correct answer is D) Continue to measure the client's vital signs every thirty minutes until the transfusion is complete. This instruction is crucial because monitoring vital signs closely during a blood transfusion helps the nurse to quickly identify any signs of a transfusion reaction, such as fever, chills, rash, or shortness of breath. By measuring vital signs every thirty minutes, the nurse can promptly intervene if any complications arise, ensuring the client's safety. Option A) Encouraging the client to increase fluid intake is not the correct instruction for the UAP in this scenario. While adequate hydration is important, it is not directly related to monitoring for a transfusion reaction. Option B) Documenting the absence of a reaction is important but should be done by the nurse, not the UAP. UAPs are typically not responsible for documenting clinical assessments or findings. Option C) Notifying the nurse if the client develops a fever is not the best instruction for the UAP. The UAP should focus on continuous monitoring of vital signs rather than waiting for the client to develop a fever before notifying the nurse. In an educational context, this question highlights the importance of close monitoring during blood transfusions and the specific responsibilities of different members of the healthcare team in ensuring patient safety and quality care. It emphasizes the significance of timely and accurate vital sign assessments in detecting and managing potential transfusion reactions.