HESI RN
HESI RN Exit Exam Capstone Questions
Question 1 of 5
The nurse is caring for a client with pancreatitis who is receiving total parenteral nutrition (TPN). Which assessment finding requires immediate intervention by the nurse?
Correct Answer: B
Rationale: In this scenario, the correct answer is option B) The client reports feeling weak and shaky, which requires immediate intervention by the nurse. This symptom could indicate hypoglycemia, a potential complication of TPN therapy in pancreatitis patients. Hypoglycemia can lead to serious consequences like seizures or loss of consciousness, thus necessitating prompt attention. Option A) Blood glucose level of 200 mg/dL may be slightly elevated but does not pose an immediate threat. Option C) The TPN bag is 5% dextrose could be a normal concentration for TPN and does not indicate an urgent issue. Option D) The client feeling thirsty may suggest dehydration, which is important to address but not as critical as potential hypoglycemia. From an educational perspective, this question highlights the importance of recognizing and prioritizing assessments in patients receiving TPN, especially those with pancreatitis. Nurses must be vigilant in monitoring for complications like hypoglycemia and be prepared to intervene promptly to ensure patient safety and well-being.
Question 2 of 5
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 3 of 5
The nurse is providing care for a client with severe anemia. Which assessment finding requires immediate intervention?
Correct Answer: C
Rationale: In this scenario, the correct answer is option C: Shortness of breath, which requires immediate intervention when caring for a client with severe anemia. Shortness of breath indicates that the client is not receiving enough oxygen, which can be a life-threatening situation. Addressing this symptom promptly is crucial to prevent further complications such as hypoxia or respiratory distress. Option A: Pale skin is a common manifestation of anemia but may not require immediate intervention unless accompanied by other concerning symptoms like dizziness or lightheadedness. Option B: Increased heart rate is a typical compensatory mechanism in anemic clients to maintain oxygen delivery to tissues. While important to monitor, it may not be the most urgent concern in this case. Option D: Fatigue is a common symptom of anemia but is not as acute as shortness of breath. It can be addressed with rest and proper nutrition over time. Educationally, understanding the priority of assessments in clients with severe anemia is vital for nurses to provide safe and effective care. Recognizing critical signs and symptoms allows for timely interventions and prevents adverse outcomes, highlighting the importance of prioritizing care based on the client's condition.
Question 4 of 5
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 5 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.