HESI RN
HESI RN Exit Exam Capstone Questions
Question 1 of 5
After administering a proton pump inhibitor, which action should the nurse take to evaluate the effectiveness of the medication?
Correct Answer: B
Rationale: In the context of administering a proton pump inhibitor (PPI), the correct action to evaluate the effectiveness of the medication is to ask the client about gastrointestinal pain (Option B). This is because PPIs work by reducing the production of stomach acid, which helps in alleviating symptoms such as heartburn, acid reflux, and stomach ulcers. Therefore, asking the client about any improvement in gastrointestinal pain will provide direct feedback on the medication's efficacy. Monitoring bowel movements (Option A) is not directly related to evaluating the effectiveness of a PPI. Vital signs (Option C) may not reflect the specific symptom relief associated with PPI use. Assessing for signs of bleeding (Option D) is important when using medications like nonsteroidal anti-inflammatory drugs (NSAIDs) but is not the primary indicator of PPI effectiveness. In an educational context, understanding the rationale behind evaluating the effectiveness of medications is crucial for nurses to provide quality patient care. By linking the mechanism of action of a medication with the assessment of specific symptoms, nurses can make informed clinical decisions and ensure optimal patient outcomes.
Question 2 of 5
An older client with SIRS has a temperature of 101.8°F, a heart rate of 110 beats per minute, and a respiratory rate of 24 breaths per minute. Which additional finding is most important to report to the healthcare provider?
Correct Answer: A
Rationale: In this scenario, the most important finding to report to the healthcare provider is option A) Serum creatinine of 2.0 mg/dL. This is indicative of acute kidney injury (AKI), a serious complication often seen in clients with systemic inflammatory response syndrome (SIRS). AKI can result from poor perfusion due to the client's elevated heart rate and low blood pressure, leading to organ damage and failure if not addressed promptly. Option B) Elevated WBC count is a common finding in clients with SIRS and does not provide specific information regarding organ function or perfusion status. Option C) Blood pressure of 100/60 mmHg is low but expected in clients with SIRS and may not directly indicate organ dysfunction. Option D) Oxygen saturation of 95% is within normal range and does not alert to a critical issue necessitating immediate attention. Educationally, understanding the significance of laboratory values in the context of a client's condition is crucial for nurses to prioritize and communicate effectively with the healthcare team. Recognizing the implications of abnormal findings like elevated serum creatinine levels can guide timely interventions and prevent further deterioration in clients with complex health conditions.
Question 3 of 5
The mother of a 2-day-old infant girl expresses concern about a 'flea bite' type rash on her daughter's body. The nurse identifies a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer?
Correct Answer: C
Rationale: In this scenario, the correct answer is C) This is a common newborn rash that will resolve after several days. This response is accurate because the description of a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen is indicative of erythema toxicum, a benign and self-limiting rash commonly seen in newborns. It typically appears in the first few days of life and resolves on its own without any treatment. Option A) We need to monitor the rash for signs of worsening or fever is incorrect because erythema toxicum is a harmless condition and does not require monitoring for worsening or fever. Option B) Your baby may have an allergic reaction to laundry detergent is incorrect as this type of rash does not indicate an allergic reaction to laundry detergent. It is a common and harmless skin condition in newborns. Option D) This is likely a bacterial infection requiring antibiotics is incorrect as erythema toxicum is not caused by a bacterial infection and does not necessitate antibiotic treatment. From an educational perspective, it is crucial for nurses to be able to differentiate between common newborn rashes to provide accurate information and reassure parents. Understanding the characteristics, causes, and management of common newborn rashes like erythema toxicum is essential for providing quality care and guidance to parents of newborns.
Question 4 of 5
A client is receiving 30 mg of enoxaparin subcutaneously twice a day. In assessing adverse effects of the medication, which serum laboratory value is most important for the nurse to monitor?
Correct Answer: B
Rationale: In the context of a client receiving enoxaparin, a low molecular weight heparin, monitoring the platelet count is crucial. Enoxaparin works by inhibiting blood clot formation, which can lead to a condition called heparin-induced thrombocytopenia (HIT), characterized by a significant drop in platelet count. Monitoring platelet levels helps detect this potentially life-threatening adverse effect early. Hemoglobin level (Option A) is not directly affected by enoxaparin and is not the most important value to monitor in this case. Activated partial thromboplastin time (aPTT) (Option C) and Prothrombin time (PT) (Option D) are more commonly used to monitor the effects of unfractionated heparin, not enoxaparin, which has a more predictable anticoagulant response and does not require routine monitoring based on these values. In an educational context, understanding the rationale behind monitoring specific laboratory values for patients on anticoagulant therapy is critical for nurses to provide safe and effective care. Emphasizing the importance of monitoring platelet count in this scenario can help nurses recognize and respond promptly to adverse effects, ultimately improving patient outcomes.
Question 5 of 5
A young woman with multiple sclerosis just received several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. What teaching should the nurse provide?
Correct Answer: A
Rationale: In this scenario, the correct answer is option A) Immunizations can trigger a relapse of the disease, so get plenty of extra rest. This is the most appropriate response because immunizations can potentially stimulate an immune response that may exacerbate symptoms in individuals with autoimmune conditions like multiple sclerosis. Encouraging the young woman to rest can help her body recover and manage any potential flare-up more effectively. Option B is incorrect because visual problems could be related to the immunizations in the context of multiple sclerosis. Option C, increasing fluid intake, may be beneficial for overall health but is not directly addressing the potential relapse triggered by the immunizations. Option D, immediate consultation for steroid therapy, is not the first-line intervention and should be reserved for cases where symptoms worsen significantly or if there is a confirmed relapse. From an educational perspective, this scenario highlights the importance of understanding the potential effects of immunizations on individuals with autoimmune conditions. Nurses play a crucial role in providing tailored education and support to help patients manage their health proactively. It also emphasizes the significance of rest and self-care in managing chronic conditions like multiple sclerosis during potential exacerbations.