HESI RN
HESI RN Exit Exam Capstone Questions
Question 1 of 5
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 2 of 5
A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement?
Correct Answer: D
Rationale: Intravenous fluids are essential for rehydrating an infant who is likely suffering from dehydration due to projectile vomiting. This condition, commonly related to pyloric stenosis, causes rapid fluid loss. Oral rehydration methods might not be sufficient or appropriate for such a young infant, especially if vomiting persists. IV therapy ensures controlled and adequate fluid replacement to stabilize the child.
Question 3 of 5
A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the therapeutic response, which assessment should the nurse obtain?
Correct Answer: D
Rationale: In this scenario, the correct assessment the nurse should obtain to evaluate the therapeutic response of a client receiving lactulose for hepatic encephalopathy is the "Level of consciousness" (Option D). This is crucial because hepatic encephalopathy is a condition characterized by altered mental status and consciousness due to liver dysfunction. Lactulose is commonly used to reduce ammonia levels in hepatic encephalopathy by promoting its excretion in the stool. Assessing the client's level of consciousness is vital as it directly reflects the effectiveness of the treatment. Improvement in consciousness levels indicates a positive response to the lactulose therapy. On the other hand, if the client's level of consciousness does not improve or worsens, it may indicate the need for further interventions or adjustments in the treatment plan. Percussion of the abdomen (Option A) is not directly related to evaluating the therapeutic response to lactulose in hepatic encephalopathy. Blood glucose level (Option B) and serum electrolytes (Option C) are important assessments in various conditions but are not specifically indicated to evaluate the response to lactulose in hepatic encephalopathy. Educationally, understanding the rationale behind selecting the correct assessment helps nurses develop critical thinking skills in assessing and managing clients with hepatic encephalopathy. It reinforces the importance of tailored assessments based on the client's condition and the treatment being provided, ultimately leading to improved patient outcomes.
Question 4 of 5
An older adult client with eye dryness reports itching and excessive tearing. Which medication group is most likely to have produced this client's symptoms?
Correct Answer: D
Rationale: The correct answer is D) Antihypertensives and anticholinergics. In this case, the client's symptoms of eye dryness, itching, and excessive tearing are likely due to the side effects of antihypertensive and anticholinergic medications. Antihypertensive medications can cause dryness of mucous membranes, including the eyes, as a common side effect. Anticholinergic medications, which inhibit the action of acetylcholine in the body, can lead to dryness of the eyes and mouth, as well as itching. Option A) Antiinfectives and antidepressants are not typically associated with symptoms of eye dryness, itching, and excessive tearing. Option B) Anticoagulants and antihistamines do not commonly cause the symptoms described by the client. Option C) Antiretrovirals and antivirals are not known to produce the specific symptoms of eye dryness, itching, and excessive tearing. In an educational context, understanding the potential side effects of medications is crucial for healthcare professionals to provide safe and effective care to older adult clients. This knowledge helps in assessing and managing medication-related symptoms and ensuring the overall well-being of the clients.
Question 5 of 5
An older client is admitted to the intensive care unit unconscious after several days of vomiting and diarrhea. The nurse inserts a urinary catheter and observes dark amber urine output. Which intervention should the nurse implement first?
Correct Answer: C
Rationale: In this scenario, the nurse should implement the intervention C) Give a bolus of 0.9% sodium chloride 1000 mL over 30 minutes first. The dark amber urine output in an older client with a history of vomiting and diarrhea indicates severe dehydration and potential hypovolemic shock. Therefore, the priority is to restore intravascular volume quickly to improve perfusion and organ function. Option A) Beginning a dopamine infusion is not the priority as it focuses on increasing blood pressure but does not address the immediate need for volume replacement. Option B) Starting potassium chloride can be dangerous in a dehydrated patient as it can lead to hyperkalemia. Option D) Administering promethazine does not address the underlying issue of dehydration and could potentially worsen the patient's condition. Educationally, this question highlights the importance of prioritizing interventions based on the patient's condition and the urgency of the situation. Understanding the signs of dehydration and shock is crucial for nurses to provide timely and appropriate care, especially in critically ill patients. It also emphasizes the significance of fluid resuscitation in managing hypovolemia and improving patient outcomes.