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. The nurse in the emergency department observes a colleague viewing the electronic health record (EHR) of a client who holds an elected position in the community. The client is not a part of the colleague's assignment. Which action should the nurse implement?
- A. Communicate the colleague's actions to the unit charge nurse
- B. Send an email to facility administration reporting the action
- C. Write an anonymous complaint to a professional website
- D. Post a comment about the action on a staff discussion board
Correct answer: A
Rationale: Viewing the EHR of a client who is not under your care is a violation of HIPAA regulations, regardless of the client's social status or your curiosity. The appropriate action to take in this situation is to communicate the colleague's actions to the unit charge nurse. The charge nurse can then escalate the issue through the appropriate channels within the organization. Reporting to the charge nurse ensures that the incident is handled internally and in accordance with organizational policies and procedures. Sending an email to facility administration, writing an anonymous complaint to a professional website, or posting a comment on a staff discussion board are not the recommended actions as they may not address the issue effectively and could potentially violate confidentiality further.
3. When planning care for a child diagnosed with rheumatic fever, what is the primary goal of nursing care?
- A. Reduce fever.
- B. Maintain fluid and electrolyte balance.
- C. Prevent cardiac damage.
- D. Maintain joint mobility and function.
Correct answer: C
Rationale: The primary goal of nursing care for a child diagnosed with rheumatic fever is to prevent cardiac damage. Rheumatic fever can lead to complications affecting the heart, making it crucial to monitor and prevent cardiac involvement to avoid long-term consequences. While addressing fever and joint pain are important aspects of care, preventing cardiac damage takes precedence in managing rheumatic fever. Therefore, choices A, B, and D are not the primary goals of nursing care in this case.
4. A patient’s serum osmolality is 305 mOsm/kg. Which term describes this patient’s body fluid osmolality?
- A. Iso-osmolar
- B. Hypo-osmolar
- C. Hyperosmolar
- D. Isotonic
Correct answer: C
Rationale: The correct term to describe a patient with a serum osmolality of 305 mOsm/kg is 'hyperosmolar.' Normal osmolality ranges from 280 to 300 mOsm/kg. A patient with an osmolality above this range is considered hyperosmolar. Choice A ('Iso-osmolar') implies an equal osmolality, which is not the case in this scenario. Choice B ('Hypo-osmolar') suggests a lower osmolality, which is incorrect based on the provided serum osmolality value. Choice D ('Isotonic') refers to a solution having the same osmolality as another solution, not describing the specific scenario of this patient being above the normal range.
5. The best indicator that the client has learned how to give an insulin self-injection correctly is when the client can:
- A. Perform the procedure safely and correctly.
- B. Critique the nurse's performance of the procedure.
- C. Explain all steps of the procedure correctly.
- D. Correctly answer a post-test about the procedure.
Correct answer: A
Rationale: The best indicator of learning is the ability to perform the procedure safely and correctly, demonstrating skill acquisition. Choice A is correct because the client's ability to perform the insulin self-injection safely and correctly shows practical understanding and application of the skill. Choice B is incorrect because critiquing the nurse's performance does not necessarily demonstrate the client's ability to carry out the procedure themselves. Choice C is incorrect as merely explaining the steps verbally does not confirm the client's practical execution of the task. Choice D is also incorrect as answering a post-test does not directly assess the client's ability to physically perform the insulin self-injection.