HESI RN
HESI RN Exit Exam Capstone Questions
Question 1 of 5
While assessing a client who is admitted with heart failure and pulmonary edema, the nurse identifies dependent peripheral edema, an irregular heart rate, and a persistent cough that produces pink blood-tinged sputum. After initiating continuous telemetry and positioning the client, which intervention should the nurse implement?
Correct Answer: D
Rationale: The client's cough producing pink, frothy sputum is indicative of pulmonary edema, which needs immediate treatment. Obtaining a sputum sample helps identify any infection that may be contributing to the pulmonary issues. Administering diuretics and notifying the provider are also important, but sputum analysis will guide specific treatment.
Question 2 of 5
A young adult visits the clinic reporting symptoms associated with gastritis. Which information in the client's history is most important for the nurse to address in the teaching plan?
Correct Answer: B
Rationale: In this scenario, option B is the most important information in the client's history for the nurse to address in the teaching plan. Consuming 10 or more drinks of alcohol every weekend can significantly contribute to the development or exacerbation of gastritis. Alcohol irritates the stomach lining, increases stomach acid production, and can lead to inflammation, all of which can worsen gastritis symptoms. Option A, occasional heartburn after eating spicy food, is a common symptom that may not necessarily indicate a serious issue like gastritis. Option C, frequent use of NSAIDs, is also a risk factor for gastritis, but alcohol consumption in this case presents a more immediate concern due to its direct impact on the stomach lining. Option D, a history of peptic ulcers, is relevant as it suggests a predisposition to gastrointestinal issues, but the current alcohol consumption poses a more urgent threat to the client's gastric health. Educationally, this question highlights the importance of recognizing modifiable risk factors in the development of gastritis and the need for tailored patient education to address these factors to promote healing and prevent further complications. Nurses play a crucial role in educating patients on lifestyle modifications to manage and prevent gastritis, making this information vital in clinical practice.
Question 3 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 4 of 5
The nurse is providing care for a client with schizophrenia who receives haloperidol decanoate 75 mg IM every 4 weeks. The client begins developing a puckering and smacking of the lips and facial grimacing. Which intervention should the nurse implement?
Correct Answer: C
Rationale: In this scenario, the correct intervention is to complete the abnormal involuntary movement scale (AIMS) for the client. The client is exhibiting signs of tardive dyskinesia, a potential side effect of antipsychotic medications like haloperidol. AIMS is a standardized tool used to assess and monitor movement disorders, including tardive dyskinesia. By completing the AIMS assessment, the nurse can objectively evaluate the severity of the client's symptoms and determine the necessity for further intervention or medication adjustments. Discontinuing the medication immediately (Option A) is not recommended without proper assessment and evaluation of the client's symptoms. Abruptly stopping antipsychotic medications can lead to withdrawal symptoms and exacerbation of underlying psychiatric conditions. Increasing the dose of haloperidol (Option B) would be contraindicated as the client is already experiencing extrapyramidal side effects. Increasing the dose can further worsen these symptoms. Monitoring the client for signs of agitation (Option D) is important in general care but does not address the specific issue of tardive dyskinesia. Without proper assessment using the AIMS tool, the nurse may miss the opportunity to address the side effects effectively. Educationally, this scenario highlights the importance of thorough assessment, using appropriate tools, and understanding the side effects of medications in psychiatric nursing practice. It emphasizes the need for a systematic approach to managing medication side effects to ensure optimal client care and safety.
Question 5 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.