HESI RN
HESI RN Exit Exam 2023 Capstone
1. A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states 'I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects.' The nurse should understand that
- A. A referral is needed to the psychiatrist who is to provide the client with answers
- B. The client has a right to know about the prescribed medications
- C. Such education is an independent decision of the individual nurse whether or not to teach clients about their medications
- D. Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects
Correct answer: B
Rationale: The correct answer is B. The client has a legal right to be informed about their treatment, including medication uses and side effects, as part of informed consent. This helps ensure that the client can make an informed decision about their care. Choice A is incorrect because the nurse can provide the client with information about their medications. Choice C is incorrect as it is not an independent decision of the nurse but a professional responsibility to educate clients. Choice D is incorrect as knowledge about medication side effects can actually empower clients to manage their condition effectively.
2. A client with acute kidney injury has an elevated creatinine level. What is the nurse's priority intervention?
- A. Administer diuretics as prescribed.
- B. Prepare the client for dialysis.
- C. Restrict the client’s fluid intake.
- D. Notify the healthcare provider immediately.
Correct answer: B
Rationale: The correct answer is B: Prepare the client for dialysis. Clients with acute kidney injury and elevated creatinine may require dialysis to support kidney function and remove waste products from the blood. Preparing for dialysis ensures timely intervention in preventing further complications. Administering diuretics (Choice A) may worsen the client's condition by further compromising kidney function. Restricting fluid intake (Choice C) may be necessary in some cases, but it is not the priority over preparing for dialysis. Notifying the healthcare provider (Choice D) is important, but the immediate priority is to prepare for dialysis to address the acute kidney injury and elevated creatinine level.
3. 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.
4. 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.
5. A client is admitted with a severe burn injury. What is the nurse's priority intervention?
- A. Monitor the client's urine output.
- B. Administer intravenous fluids.
- C. Apply cool, moist compresses to the burn area.
- D. Cover the burn area with a sterile dressing.
Correct answer: B
Rationale: The correct answer is B: Administer intravenous fluids. In a client with severe burn injury, the priority intervention is to administer intravenous fluids to prevent shock. Monitoring urine output (Choice A) is important but not the priority. Applying cool, moist compresses (Choice C) can be beneficial but is not the priority over fluid resuscitation. Covering the burn area with a sterile dressing (Choice D) is important for wound care but is not the immediate priority in managing severe burns.
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