HESI RN
HESI RN Exit Exam Capstone Questions
Question 1 of 4
The nurse is caring for a client with a suspected myocardial infarction (MI). Which laboratory test result is most indicative of a recent MI?
Correct Answer: A
Rationale: In the context of caring for a client with a suspected myocardial infarction (MI), understanding the significance of laboratory test results is crucial for timely and accurate intervention. In this scenario, the correct answer is A) Elevated troponin levels. Troponin is a protein released into the bloodstream when there is damage to the heart muscle, making it a highly specific marker for myocardial infarction. Elevated troponin levels indicate cardiac muscle injury, confirming the diagnosis of a recent MI. Option B) Increased white blood cell count is not specific to MI but rather indicates a general inflammatory response, which can be seen in various conditions. Option C) Increased lactate dehydrogenase (LDH) is not as specific to cardiac muscle damage as troponin and can be elevated in multiple organ systems, making it less indicative of an MI. Option D) Elevated C-reactive protein (CRP) is a marker of inflammation and is not specific to myocardial infarction. While inflammation may be present in MI, it is not as specific as troponin in diagnosing cardiac muscle damage. Educationally, understanding the nuances of these laboratory tests helps nurses differentiate between various conditions and provide appropriate care. Recognizing the significance of troponin in diagnosing MI can lead to prompt treatment and improved patient outcomes.
Question 2 of 4
The nurse is caring for a client with acute pancreatitis who is reporting severe abdominal pain. Which nursing intervention should the nurse implement first?
Correct Answer: B
Rationale: In this scenario, administering the prescribed pain medication (Option B) should be the first nursing intervention for a client with acute pancreatitis experiencing severe abdominal pain. Pain management is crucial in this situation to provide relief, improve comfort, and support the client's overall well-being. Uncontrolled pain can lead to complications and hinder the client's recovery process. Assessing the client's bowel sounds (Option A) is important in the overall care of a client with pancreatitis, but it is not the priority when the client is in severe pain. Administering pain medication takes precedence to address the immediate discomfort and distress. Encouraging the client to sit upright (Option C) may be beneficial in some cases to promote comfort and aid digestion, but in the presence of severe pain, this intervention may exacerbate the client's discomfort. Providing clear fluids to the client (Option D) is important for hydration and nutritional support in pancreatitis management, but it does not address the client's immediate need for pain relief. In an educational context, understanding the prioritization of nursing interventions based on the client's condition and needs is essential for providing safe and effective care. Pain management is a fundamental aspect of nursing care, especially in acute conditions like pancreatitis, where timely intervention can significantly impact the client's outcomes.
Question 3 of 4
The nurse is caring for a client with deep vein thrombosis (DVT) who is receiving anticoagulant therapy. Which intervention should the nurse implement to prevent complications?
Correct Answer: A
Rationale: In caring for a client with deep vein thrombosis (DVT) receiving anticoagulant therapy, elevating the affected leg is the most appropriate intervention to prevent complications. Elevating the leg helps reduce swelling and improve blood flow, thus decreasing the risk of clot progression and embolism formation. Encouraging early ambulation might dislodge the clot and lead to a pulmonary embolism, making it a potentially harmful intervention for a client with DVT. Performing frequent range-of-motion exercises can also dislodge the clot or cause trauma to the affected area, increasing the risk of complications. Applying ice packs is not recommended as cold therapy may vasoconstrict blood vessels, potentially exacerbating the clot. In an educational context, understanding the rationale behind each intervention is crucial for nursing practice. Nurses must possess a sound knowledge base to provide safe and effective care to clients with DVT. By comprehending the pathophysiology of DVT and the effects of various interventions, nurses can make informed decisions to promote positive patient outcomes.
Question 4 of 4
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. Which assessment finding indicates that the client's oxygenation is improving?
Correct Answer: A
Rationale: In caring for a client with COPD receiving oxygen therapy, a pulse oximetry reading of 94% indicates improving oxygenation. Oxygen saturation levels above 92-94% are considered optimal for most patients. This assessment finding suggests that the therapy is effectively increasing the client's oxygen levels. Option B, an increase in heart rate, is not indicative of improved oxygenation but can be a sign of stress or other factors influencing heart function. Option C, an increase in respiratory rate, may indicate the client is working harder to breathe, which is not a sign of improved oxygenation. Option D, increased energy levels, can be subjective and may not directly correlate with improved oxygenation. Educationally, understanding the significance of pulse oximetry readings in assessing oxygenation status is crucial for nurses caring for clients with respiratory conditions. It allows for prompt intervention and evaluation of the effectiveness of oxygen therapy, leading to better patient outcomes.