HESI RN
HESI RN Exit Exam Capstone
1. The nurse observes that a client’s wrist restraint is secured to the side rail of the bed. What action should the nurse take?
- A. Ensure that the restraint is snug against the client’s wrist.
- B. Reposition the restraint tie onto the bedframe.
- C. Double knot the restraint to ensure safety.
- D. Leave the restraint in place and notify the healthcare provider.
Correct answer: B
Rationale: The correct action for the nurse to take is to reposition the restraint tie onto the bedframe. Restraints should always be secured to the bedframe, not the side rails, to prevent injury to the client in case the bed is adjusted. Choice A is incorrect because the issue is with the attachment point, not the snugness of the restraint. Choice C is incorrect as double knotting the restraint does not address the incorrect attachment point. Choice D is incorrect as the nurse should not leave the restraint in the wrong position; instead, it should be moved to the correct location on the bedframe.
2. After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, 'I have had it with that client. I just can't do anything that pleases him. I'm not going in there again.' The nurse should respond by saying
- A. He has a lot of problems. You need to have patience with him.
- B. I will talk with him and try to figure out what to do.
- C. He is scared and taking it out on you. Let's talk to figure out what to do.
- D. Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day.
Correct answer: C
Rationale: The correct response is to acknowledge the UAP's feelings while exploring the client's behavior. By stating, 'He is scared and taking it out on you. Let's talk to figure out what to do,' the nurse shows empathy and readiness to address the situation collaboratively. This approach helps maintain a therapeutic environment for both the UAP and the client. Choices A and D are dismissive and do not address the underlying issue or provide support. Choice B, while showing willingness to intervene, lacks the understanding of the client's potential fear and does not address the UAP's feelings.
3. A nurse is caring for a client with a chest tube following lung surgery. What is the most important intervention to ensure the chest tube functions properly?
- A. Clamp the tube if there is excessive drainage
- B. Empty the drainage chamber every 2 hours
- C. Keep the drainage system below chest level
- D. Milk the tube to prevent clots from forming
Correct answer: C
Rationale: The correct answer is C. Keeping the chest tube drainage system below chest level ensures that gravity assists with drainage and prevents fluid or air from flowing back into the pleural space, which could compromise lung function. Clamping the tube if there is excessive drainage (choice A) is incorrect as it can lead to a buildup of pressure and compromise the drainage system. Emptying the drainage chamber every 2 hours (choice B) is important but not as crucial as maintaining the drainage system below chest level. Milking the tube to prevent clots from forming (choice D) is incorrect and could lead to complications such as tube occlusion or damage to the tissue.
4. The nurse is providing care for a client with schizophrenia who receives haloperidol decanoate 75 mg IM every 4 weeks. The client begins developing puckering and smacking of the lips and facial grimacing. Which intervention should the nurse implement?
- A. Discontinue the medication immediately
- B. Increase the dose of haloperidol
- C. Complete the abnormal involuntary movement scale (AIMS)
- D. Monitor the client for signs of agitation
Correct answer: C
Rationale: These symptoms are characteristic of tardive dyskinesia, a side effect of long-term antipsychotic use. The nurse should assess the severity of these movements using the AIMS scale and report to the healthcare provider for further management. Discontinuing the medication abruptly (Choice A) can lead to withdrawal symptoms and worsening of the condition. Increasing the dose of haloperidol (Choice B) can exacerbate the symptoms of tardive dyskinesia. Monitoring for signs of agitation (Choice D) is important but does not address the specific side effect described.
5. A client with a seizure disorder is prescribed phenytoin. What is the most important teaching the nurse should provide?
- A. Take phenytoin with antacids to reduce stomach upset.
- B. Maintain a consistent dosing schedule to prevent seizures.
- C. Monitor for excessive drowsiness and dizziness.
- D. Take the medication at bedtime to reduce seizure risk.
Correct answer: B
Rationale: The most important teaching the nurse should provide to a client prescribed phenytoin is to maintain a consistent dosing schedule to prevent seizures. Phenytoin is an antiepileptic drug, and missing doses can increase the risk of seizures. Option A is incorrect because antacids can interact with phenytoin and reduce its absorption. Option C is important but not the most critical teaching as compared to maintaining a consistent dosing schedule. Option D is incorrect because the timing of phenytoin administration should be consistent rather than specifically at bedtime.
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