HESI RN
HESI RN Exit Exam Capstone Questions
Question 1 of 5
A client with atrial fibrillation is prescribed warfarin, and their INR is elevated. What is the nurse's priority action?
Correct Answer: D
Rationale: The correct answer is D) Notify the healthcare provider immediately and hold the next dose of warfarin. Rationale: - Warfarin is an anticoagulant medication used to prevent blood clots. An elevated INR indicates that the blood is taking longer to clot, putting the client at risk for bleeding complications. - In this situation, the nurse's priority is to ensure the client's safety by notifying the healthcare provider promptly. Holding the next dose of warfarin can help prevent further elevation of the INR and reduce the risk of bleeding. - Administering vitamin K to reverse the effects of warfarin is not the initial action to take as it may interfere with the client's anticoagulation therapy. - Monitoring the client for signs of bleeding is important, but it is not the priority over taking immediate action to address the elevated INR. - Increasing the client's warfarin dosage when the INR is already elevated can further potentiate the risk of bleeding and is contraindicated. Educational context: Understanding the management of anticoagulation therapy is crucial for nurses caring for clients with conditions like atrial fibrillation. Recognizing the significance of monitoring INR levels and taking appropriate actions in response to abnormalities is essential to prevent complications and ensure patient safety. Nurses must be able to prioritize interventions based on the client's condition and medication regimen to provide effective and safe care.
Question 2 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 3 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 4 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.
Question 5 of 5
A client asks the nurse for information about reducing risk factors for BPH. Which information should the nurse provide?
Correct Answer: A
Rationale: In the context of BPH (Benign Prostatic Hyperplasia), increasing physical activity is the most appropriate answer. Regular physical activity helps in maintaining a healthy weight and can reduce the risk of developing BPH. Exercise also improves overall health and circulation, which can have a positive impact on prostate health. Decreasing alcohol consumption (option B) can be beneficial for overall health but is not directly linked to reducing the risk factors for BPH. Similarly, reducing intake of dairy products (option C) and avoiding caffeine and spicy foods (option D) may help alleviate symptoms for some individuals with BPH, but they are not primary strategies for reducing the risk factors. From an educational perspective, it is important for nurses to provide evidence-based information to clients. Understanding the rationale behind each option can help nurses convey accurate information to clients seeking guidance on reducing their risk for BPH. By emphasizing the importance of physical activity, nurses can empower clients to make informed lifestyle choices that promote prostate health and overall well-being.