HESI RN
HESI RN Exit Exam Capstone
1. At 0600 while admitting a woman for a scheduled repeat cesarean section, the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?
- A. Cancel the surgery
- B. Inform the anesthesia care provider
- C. Ask the client if she has had any other liquids
- D. Proceed with routine preparations
Correct answer: B
Rationale: Drinking liquids before surgery can increase the risk of aspiration during anesthesia. Therefore, the anesthesia care provider must be informed immediately to determine how to proceed, as this could delay or alter the surgical plan. Canceling the surgery without consulting the anesthesia care provider would be premature and could potentially lead to unnecessary actions. Asking the client if she has had any other liquids is important but not the first priority. Proceeding with routine preparations without addressing the potential issue of ingesting liquids before surgery could compromise the client's safety.
2. While changing a client's chest tube dressing, the nurse notes a cracking sensation when gentle pressure is applied to the skin at the insertion site. What should the nurse do next?
- A. Apply a pressure dressing at the chest tube site.
- B. Administer an oral antihistamine per PRN order.
- C. Assess the client for allergies to topical cleaning agents.
- D. Measure the area of crackling and swelling.
Correct answer: D
Rationale: Measuring the area of crackling and swelling is essential in monitoring the progression of subcutaneous emphysema, which can result from air leaking into the tissues around the chest tube insertion site. This technique helps evaluate the extent of the issue and guides further interventions. Applying a pressure dressing (choice A) might exacerbate the condition by trapping more air. Administering an oral antihistamine (choice B) is not indicated for subcutaneous emphysema. Assessing for allergies to topical cleaning agents (choice C) is not the priority in this situation compared to evaluating and managing the subcutaneous emphysema.
3. A client with heart failure is prescribed furosemide. The nurse notes that the client's potassium level is 3.1 mEq/L. What is the nurse's priority action?
- A. Administer a potassium supplement
- B. Encourage the client to eat potassium-rich foods
- C. Hold the next dose of furosemide
- D. Increase the client's fluid intake
Correct answer: A
Rationale: A potassium level of 3.1 mEq/L is considered low, indicating hypokalemia. Administering a potassium supplement is the nurse's priority action to prevent complications such as cardiac arrhythmias associated with low potassium levels. Encouraging the client to eat potassium-rich foods is beneficial in the long term but may not rapidly correct the low potassium level. Holding the next dose of furosemide may worsen the client's heart failure symptoms. Increasing the client's fluid intake is not the priority action in this situation; addressing the low potassium level takes precedence to prevent potential serious complications.
4. When speaking with a group of teens about chemotherapy side effects for cancer, which side effect would the nurse expect this group to be more interested in discussing?
- A. Mouth sores
- B. Fatigue
- C. Diarrhea
- D. Hair loss
Correct answer: D
Rationale: Teens are more likely to be concerned with hair loss when discussing chemotherapy side effects because it is a visible and emotionally impactful side effect for them. While all the listed side effects are important to consider, hair loss can have a significant impact on a teenager's self-image and emotional well-being, making it a key point of interest for this age group. Mouth sores, fatigue, and diarrhea are also common side effects of chemotherapy, but they may not carry the same level of emotional weight and visibility as hair loss for teens.
5. A client with atrial fibrillation is prescribed warfarin, and their INR is elevated. What is the nurse's priority action?
- A. Administer a dose of vitamin K to reverse the effects of warfarin.
- B. Monitor the client for signs of bleeding, such as bruising or nosebleeds.
- C. Increase the client’s warfarin dosage to prevent clot formation.
- D. Notify the healthcare provider immediately and hold the next dose of warfarin.
Correct answer: D
Rationale: An elevated INR in clients taking warfarin increases the risk of bleeding, indicating the dose may be too high. The nurse's priority action is to notify the healthcare provider immediately and hold the next dose of warfarin to prevent bleeding complications. Administering vitamin K is not the first-line intervention for an elevated INR. Monitoring for signs of bleeding is important but not the priority over contacting the healthcare provider. Increasing the warfarin dosage can exacerbate the risk of bleeding and is contraindicated.
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