HESI RN
HESI RN Exit Exam 2023 Capstone
1. A client receiving chemotherapy reports severe nausea. What should the nurse implement first?
- A. Administer an antiemetic as prescribed.
- B. Offer the client small, frequent meals.
- C. Provide the client with crackers and water.
- D. Encourage the client to eat a bland diet.
Correct answer: A
Rationale: The correct answer is A: Administer an antiemetic as prescribed. When a client receiving chemotherapy reports severe nausea, the priority action is to administer an antiemetic medication as prescribed. Antiemetics help alleviate nausea and prevent complications associated with chemotherapy, such as dehydration and malnutrition. Options B, C, and D focus on dietary interventions which can be helpful but addressing the severe nausea with antiemetic medication takes precedence to provide immediate relief and ensure the client's comfort and well-being.
2. A client with pneumonia is receiving antibiotics and oxygen therapy. What assessment finding requires immediate intervention?
- A. Productive cough with yellow sputum.
- B. Oxygen saturation of 88%.
- C. Respiratory rate of 20 breaths per minute.
- D. Heart rate of 90 beats per minute.
Correct answer: B
Rationale: An oxygen saturation of 88% indicates hypoxemia, which is a critical condition requiring immediate intervention to improve oxygenation. Hypoxemia can lead to tissue hypoxia and further complications. A productive cough with yellow sputum is common in pneumonia but may not require immediate intervention unless it worsens or is associated with other concerning symptoms. A respiratory rate of 20 breaths per minute is within the normal range, indicating adequate ventilation. A heart rate of 90 beats per minute is also within a normal range and may not require immediate intervention unless it is accompanied by other abnormal findings.
3. The client has been diagnosed with hypertension, and the nurse is providing education on dietary changes. Which food should the client be advised to avoid?
- A. Bananas
- B. Processed meats
- C. Low-fat yogurt
- D. Whole grains
Correct answer: B
Rationale: Processed meats should be avoided by clients with hypertension as they are high in sodium, which can contribute to elevated blood pressure. It is essential to limit the intake of high-sodium foods to help manage hypertension. Bananas, low-fat yogurt, and whole grains are generally beneficial for heart health due to their nutrient content and should not be avoided in a heart-healthy diet.
4. A client with rheumatoid arthritis is prescribed disease-modifying antirheumatic drugs (DMARDs). What should the nurse monitor for?
- A. Monitor for signs of liver toxicity.
- B. Assess for gastrointestinal side effects, such as nausea or diarrhea.
- C. Monitor for signs of infection, such as fever or sore throat.
- D. Administer DMARDs with meals to prevent gastrointestinal upset.
Correct answer: C
Rationale: Correct Answer: Monitoring for signs of infection, such as fever or sore throat, is crucial when a client with rheumatoid arthritis is prescribed disease-modifying antirheumatic drugs (DMARDs). DMARDs can suppress the immune system, making individuals more susceptible to infections. Early detection of infections allows for prompt treatment and helps prevent complications. Choices A, B, and D are incorrect because while liver toxicity and gastrointestinal side effects are possible side effects of DMARDs, monitoring for signs of infection takes priority due to the increased risk of infections associated with these medications.
5. A client receiving heparin therapy develops sudden chest pain and dyspnea. What should the nurse do first?
- A. Administer oxygen and elevate the head of the bed.
- B. Administer sublingual nitroglycerin as prescribed.
- C. Assess for signs of bleeding at the injection site.
- D. Administer a PRN dose of albuterol.
Correct answer: A
Rationale: In this scenario, the priority action for the nurse is to administer oxygen and elevate the head of the bed. These interventions help relieve dyspnea and chest pain, which can be indicative of a pulmonary embolism or other complications during heparin therapy. Administering nitroglycerin (Choice B) is not the initial priority in this situation as the client's symptoms are not suggestive of angina. Assessing for bleeding (Choice C) is important but not the first action needed to address chest pain and dyspnea. Administering albuterol (Choice D) is not indicated unless there are specific respiratory issues requiring it, which are not described in the scenario.
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