HESI RN
HESI RN Exit Exam 2023 Capstone
1. An older adult client with chronic emphysema is admitted with acute onset of weakness, palpitation, and vomiting. Which information is most important for the nurse to obtain during the initial interview?
- A. Medication compliance over the past few weeks.
- B. Recent sleep patterns and rest.
- C. Recent history of smoking.
- D. Activity level prior to symptom onset.
Correct answer: A
Rationale: The correct answer is A: Medication compliance over the past few weeks. In a client with chronic emphysema experiencing acute symptoms, it is crucial to assess medication compliance as it directly impacts symptom control and disease management. Ensuring the client has been adherent to their prescribed medications can provide insights into potential exacerbating factors or the need for adjustments in the treatment plan. Choices B, C, and D are less critical during the initial assessment compared to medication compliance. Recent sleep patterns and rest (choice B) may be relevant but are secondary to ensuring proper medication management. While smoking history (choice C) is important in chronic lung conditions, the immediate focus should be on the current status of medication use. Activity level prior to symptom onset (choice D) is also pertinent but not as crucial as confirming medication compliance to address the acute symptoms.
2. While auscultating heart sounds, the nurse hears a swishing sound. How should this sound be documented?
- A. Heart murmur.
- B. Murmur.
- C. S3 sound.
- D. S4 sound.
Correct answer: B
Rationale: The correct answer is B: 'Murmur.' A murmur is a swishing sound heard during auscultation, typically caused by turbulent blood flow through the heart or valves. Choices C and D, 'S3 sound' and 'S4 sound,' refer to specific heart sounds associated with different cardiac conditions, not the general description of a swishing sound. Choice A, 'Heart murmur,' is redundant as 'murmur' alone is sufficient to describe the swishing sound heard.
3. The nurse is planning to administer two medications at 0900. Which property of the drugs indicates a need to monitor the client for toxicity?
- A. Short half-life
- B. High therapeutic index
- C. Highly protein-bound
- D. Low bioavailability
Correct answer: C
Rationale: The correct answer is C, 'Highly protein-bound.' Drugs that are highly protein-bound can displace from protein-binding sites, leading to increased free drug levels in the blood, which can result in toxicity. Monitoring the client for toxicity is crucial when administering highly protein-bound drugs. Choices A, B, and D are incorrect. A short half-life does not necessarily indicate a need for monitoring toxicity; a high therapeutic index indicates a wide safety margin between the effective dose and the toxic dose, reducing the risk of toxicity; low bioavailability refers to the fraction of the drug that reaches the systemic circulation unchanged and does not directly relate to the risk of toxicity.
4. What information should the nurse include in the client's health record after a fall in the bathroom?
- A. Client fell while trying to go to the bathroom
- B. The UAP left the client alone and a fall occurred
- C. The client was found on the floor with no pulse
- D. The client fell, sustaining a fracture to the left hip
Correct answer: D
Rationale: The correct answer is D because the nurse should document factual, objective information such as the injury sustained by the client. Reporting the specific injury, like a fracture to the left hip, is crucial for accurate medical records. Choices A, B, and C lack specific detail about the injury and focus on different aspects of the fall that are not as pertinent for the health record. Choice A only mentions the fall without specifying the injury, choice B introduces blame without focusing on the client's condition, and choice C adds unnecessary information about the client's pulse which is not directly related to the fall injury.
5. A client with diabetes mellitus reports tingling in their feet. What is the nurse's best intervention?
- A. Advise the client to avoid wearing tight shoes.
- B. Refer the client to a podiatrist for foot care.
- C. Teach the client about blood sugar control and foot care.
- D. Administer insulin as prescribed.
Correct answer: C
Rationale: The correct intervention for a client with diabetes mellitus experiencing tingling in their feet is to teach the client about blood sugar control and foot care. This is essential because tingling in the feet can be a sign of neuropathy, a common complication of diabetes. Educating the client on maintaining proper blood sugar levels and foot care practices can help manage neuropathy symptoms and prevent complications like ulcers or infections. Advising the client to avoid tight shoes (Choice A) may help with comfort but does not address the underlying issue. Referring the client to a podiatrist (Choice B) is important for foot care but does not directly address blood sugar control. Administering insulin (Choice D) is not the priority for managing tingling in the feet related to neuropathy.
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