HESI RN
HESI RN Exit Exam 2023 Capstone
1. 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.
2. Prior to surgery, written consent must be obtained. What is the nurse's legal responsibility with regard to obtaining written consent?
- A. Witness the consent and sign the form as a witness
- B. Inform the client of alternatives to the procedure
- C. Explain the procedure in detail to the client
- D. Determine that the surgical consent form has been signed and is included in the client's record
Correct answer: D
Rationale: The nurse's legal responsibility is to ensure that informed consent has been obtained by verifying that the client has signed the form and that it is included in the record. Witnessing the consent and signing as a witness is not the nurse's role, as this is typically done by a neutral party. Informing the client of alternatives to the procedure and explaining the procedure in detail are responsibilities of the healthcare provider performing the surgery, not the nurse.
3. A client with a ruptured spleen underwent an emergency splenectomy. Twelve hours later, the client’s urine output is 25 ml/hour. What is the most likely cause?
- A. This is a normal finding after surgery.
- B. Oliguria signals tubular necrosis related to hypoperfusion.
- C. Oliguria signals dehydration and fluid loss.
- D. Urine output of 25 ml/hour is an expected finding after splenectomy.
Correct answer: B
Rationale: Oliguria, or decreased urine output, after surgery can indicate tubular necrosis due to hypoperfusion, which may require intervention to restore renal function. Choice A is incorrect as oliguria is not a normal finding after surgery. Choice C is incorrect because dehydration is less likely in this context compared to tubular necrosis. Choice D is incorrect as a urine output of 25 ml/hour is not expected after splenectomy and should raise concern for renal impairment.
4. The nurse is assessing a client with a history of schizophrenia who reports feeling sedated after starting a new antipsychotic medication. Which intervention is most appropriate?
- A. Reassure the client that sedation will subside with continued use
- B. Instruct the client to take the medication at bedtime
- C. Teach the client to take the medication with food
- D. Consult the healthcare provider to reduce the dosage
Correct answer: B
Rationale: Instructing the client to take the medication at bedtime is the most appropriate intervention. Taking antipsychotic medications at bedtime can help reduce the impact of sedation on the client's daily activities. This approach allows the client to sleep through the sedative effects. Choice A is incorrect because just reassuring the client may not address the immediate issue of sedation. Choice C is incorrect as taking the medication with food does not directly address the sedation concern. Choice D is not the first-line intervention; adjusting the dosage should be done by the healthcare provider after assessing the client's response to the medication.
5. A client with hypothyroidism is prescribed levothyroxine. What assessment finding suggests the medication is effective?
- A. Improved tolerance to cold.
- B. Decreased fatigue and improved energy levels.
- C. Reduced anxiety and improved mood.
- D. Increased sensitivity to heat.
Correct answer: B
Rationale: The correct answer is B: Decreased fatigue and improved energy levels. Levothyroxine is a medication used to treat hypothyroidism by providing the body with the thyroid hormone it lacks. Therefore, a positive response to the medication would manifest as decreased fatigue and improved energy levels due to the correction of the thyroid hormone imbalance. Choices A, C, and D are incorrect because improved tolerance to cold, reduced anxiety, and increased sensitivity to heat are not direct indicators of the effectiveness of levothyroxine in managing hypothyroidism.
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