HESI RN
HESI Exit Exam RN Capstone
1. Why is it important for the healthcare provider to monitor blood pressure in clients receiving antipsychotic drugs?
- A. Orthostatic hypotension is a common side effect.
- B. Most antipsychotic drugs cause elevated blood pressure.
- C. This provides information on the amount of sodium allowed in the diet.
- D. It will indicate the need to institute antiparkinsonian drugs.
Correct answer: A
Rationale: Corrected Question: Monitoring blood pressure in clients receiving antipsychotic drugs is crucial because orthostatic hypotension is a common side effect. Orthostatic hypotension can lead to a sudden drop in blood pressure upon standing, increasing the risk of falls and related injuries. Therefore, regular blood pressure monitoring helps healthcare providers detect and manage this potential side effect. Incorrect Choices Rationale: - Choice B is incorrect because while antipsychotic drugs can have various side effects, causing elevated blood pressure is not a common effect associated with them. - Choice C is unrelated to blood pressure monitoring in clients receiving antipsychotic drugs. Monitoring blood pressure in this context aims to detect and manage side effects of the medication, not to assess sodium intake. - Choice D is incorrect as monitoring blood pressure in clients receiving antipsychotic drugs is primarily aimed at detecting orthostatic hypotension, not as an indicator for instituting antiparkinsonian drugs.
2. The nurse is developing a teaching plan for a client receiving chemotherapy. Which of the following should be the nurse's first priority?
- A. The client will maintain adequate nutrition.
- B. The client will manage side effects of treatment.
- C. The client will recognize signs and symptoms of infection.
- D. The client will experience a reduction in pain.
Correct answer: C
Rationale: The correct answer is C. Recognizing signs and symptoms of infection should be the nurse's first priority when developing a teaching plan for a client receiving chemotherapy. Chemotherapy often compromises the immune system, making patients more susceptible to infections. Early identification and prompt treatment of infections are crucial to prevent complications. Options A, B, and D are important aspects of care but recognizing signs of infection takes precedence due to the potential life-threatening consequences in clients undergoing chemotherapy treatment.
3. A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client's pulse and respirations, what should be the function of the second nurse?
- A. Relieve the nurse performing CPR
- B. Go get the code cart
- C. Participate with the compressions or breathing
- D. Validate the client's advanced directive
Correct answer: C
Rationale: The correct answer is C. The second nurse should assist with compressions or breathing to ensure the patient receives adequate care during CPR. This immediate intervention is crucial in maintaining blood circulation and oxygenation to vital organs. Choice A is incorrect because simply relieving the nurse performing CPR may lead to a delay in essential life-saving measures. Choice B is incorrect as the primary focus should be on providing direct assistance rather than fetching equipment. Choice D is incorrect as validating the client's advanced directive is not the priority in this emergency situation.
4. Which of these clients, all in the terminal stage of cancer, is least appropriate to suggest the use of patient-controlled analgesia (PCA) with a pump?
- A. A young adult with a history of Down syndrome
- B. A teenager who reads at a 4th-grade level
- C. An elderly client with numerous arthritic nodules on the hands
- D. A preschooler with intermittent alertness episodes
Correct answer: D
Rationale: The correct answer is D. A preschooler with intermittent alertness episodes is not a suitable candidate for patient-controlled analgesia (PCA) due to their inability to effectively manage the system. In the context of terminal cancer, it is crucial for the patient to be able to utilize the PCA system appropriately to manage pain effectively. Preschoolers may not have the cognitive ability or understanding to operate a PCA pump compared to the other clients. Choices A, B, and C present clients with conditions that do not inherently impede their ability to use a PCA pump effectively.
5. A client tells the nurse, 'I have something very important to tell you if you promise not to tell.' The best response by the nurse is
- A. I must document and report any information.
- B. I can't make such a promise.
- C. That depends on what you tell me.
- D. I must report everything to the treatment team.
Correct answer: B
Rationale: The correct answer is B because the nurse cannot promise confidentiality in this context. It is essential to prioritize the safety and well-being of the client and others. Certain information, such as harm to oneself or others, must be reported to ensure appropriate interventions are taken. Choice A is incorrect because while documentation is important, confidentiality cannot be guaranteed in this situation. Choice C is incorrect as the nurse should not make promises that may conflict with their professional responsibilities. Choice D is incorrect as reporting everything to the treatment team without discretion may breach client confidentiality.
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