HESI RN
HESI 799 RN Exit Exam Capstone
1. A client with a head injury reports severe nausea. What is the nurse's priority action?
- A. Administer anti-nausea medication as prescribed.
- B. Prepare the client for a CT scan.
- C. Elevate the head of the bed and provide an emesis basin.
- D. Notify the healthcare provider immediately.
Correct answer: D
Rationale: Severe nausea in a client with a head injury may be a sign of increased intracranial pressure. The nurse should notify the healthcare provider immediately to ensure timely intervention, as increased pressure can lead to further complications such as brain herniation. Administering anti-nausea medication or preparing for a CT scan may delay necessary treatment for the underlying cause of the nausea, which could be related to the head injury. Elevating the head of the bed and providing an emesis basin may help manage symptoms but should not be the priority over addressing the potential increase in intracranial pressure.
2. A 6-year-old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is more important for the nurse to implement?
- A. Graph the daily weight for the past week.
- B. Decrease IV flow rate.
- C. Assess bilateral lung sounds.
- D. Restrict intake of oral fluids.
Correct answer: C
Rationale: Assessing bilateral lung sounds is crucial in this scenario as it can provide essential information about potential fluid accumulation in the lungs, indicating worsening heart failure. This assessment can guide immediate interventions to prevent further deterioration in the patient's condition.
3. A client in the postanesthesia care unit has an as-needed prescription for ondansetron (Zofran). Which of the following occurrences would prompt the nurse to administer this medication to the client?
- A. Paralytic ileus
- B. Incisional pain
- C. Urine retention
- D. Nausea and vomiting
Correct answer: D
Rationale: The correct answer is D: Nausea and vomiting. Ondansetron is an antiemetic used to manage postoperative nausea and vomiting, as well as nausea and vomiting related to chemotherapy. It is not indicated for treating paralytic ileus, incisional pain, or urine retention. Paralytic ileus is a condition of the gastrointestinal tract characterized by the paralysis of intestinal muscles, which would not be treated with ondansetron. Incisional pain is typically managed with analgesics, not antiemetics. Urine retention is a urinary issue that does not involve nausea and vomiting, making ondansetron an inappropriate choice for this condition.
4. A 7-year-old child with a history of asthma presents to the clinic with shortness of breath and wheezing. The nurse notes that the child’s peak flow reading is in the red zone. What should the nurse do first?
- A. Administer a bronchodilator
- B. Reassess the peak flow reading
- C. Notify the healthcare provider
- D. Provide oxygen therapy
Correct answer: A
Rationale: When a child with asthma presents with shortness of breath and wheezing, and the peak flow reading is in the red zone, indicating severe airflow limitation, the priority intervention is to administer a bronchodilator. Bronchodilators help dilate the airways quickly, improving airflow and assisting with breathing. Reassessing the peak flow reading is important but not the first action to take in a severe asthma exacerbation. Notifying the healthcare provider can be done after initiating immediate treatment with a bronchodilator. Providing oxygen therapy may be needed in some cases, but addressing the airway constriction with a bronchodilator should come first to improve ventilation.
5. The patient about to undergo gynecological surgery is put on nil by mouth for ____ before surgery to prevent aspiration.
- A. 2-4 hours
- B. 3-5 hours
- C. 4-6 hours
- D. 5-7 hours
Correct answer: C
Rationale: Patients undergoing gynecological surgery are typically advised to be nil by mouth for 4-6 hours before the procedure to reduce the risk of aspiration. This duration allows the stomach to empty its contents, decreasing the likelihood of regurgitation and aspiration of stomach contents during surgery. Choices A, B, and D have shorter durations and may not provide sufficient time for adequate gastric emptying, increasing the risk of aspiration.