HESI RN
HESI 799 RN Exit Exam Capstone
1. A client with a history of deep vein thrombosis (DVT) is prescribed warfarin. Which laboratory value should the nurse monitor to assess the therapeutic effect of this medication?
- A. Platelet count
- B. Prothrombin time (PT)
- C. White blood cell count
- D. Hemoglobin level
Correct answer: B
Rationale: Prothrombin time (PT) is the correct laboratory value to monitor to assess the therapeutic effect of warfarin. Warfarin works by inhibiting clotting factors, and PT measures the time it takes for blood to clot. Monitoring PT helps ensure that the medication is working effectively to prevent clot formation without causing excessive bleeding. Platelet count (Choice A) is not specific to warfarin therapy and assesses the number of platelets in the blood. White blood cell count (Choice C) and hemoglobin level (Choice D) are not directly related to monitoring the therapeutic effect of warfarin.
2. The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement?
- A. Encourage the client to drink more slowly
- B. Stop feeding and assess for signs of aspiration
- C. Elevate the head of the bed further
- D. Teach coughing and deep breathing exercises
Correct answer: B
Rationale: When an older adult with aspiration pneumonia coughs while attempting to drink, it may indicate aspiration. Aspiration can lead to serious complications. Therefore, the appropriate intervention for the nurse in this situation is to stop feeding immediately and assess the client for signs of aspiration. Encouraging the client to drink more slowly (Choice A) may not address the risk of aspiration. Elevating the head of the bed further (Choice C) is generally beneficial to prevent aspiration but is not the priority when immediate assessment is needed. Teaching coughing and deep breathing exercises (Choice D) is not appropriate when the client is actively coughing during feeding and requires immediate assessment for potential aspiration.
3. During a thyroid storm, what is the nurse's priority intervention for a client experiencing increased heart rate and tremors?
- A. Administer antithyroid medications as prescribed.
- B. Administer a beta-blocker to control the heart rate.
- C. Monitor the client's temperature closely.
- D. Prepare the client for an emergency thyroidectomy.
Correct answer: A
Rationale: The correct answer is to administer antithyroid medications as prescribed during a thyroid storm. Antithyroid medications help control the overproduction of thyroid hormones, which is crucial in managing symptoms such as increased heart rate and tremors. These symptoms can be life-threatening if not promptly addressed. Administering a beta-blocker (Choice B) may help control the heart rate, but addressing the underlying cause with antithyroid medications is the priority. Monitoring the client's temperature (Choice C) is important but not the priority intervention during a thyroid storm. Lastly, preparing the client for an emergency thyroidectomy (Choice D) is not the initial intervention for managing symptoms of a thyroid storm.
4. A client receiving total parenteral nutrition (TPN) reports nausea and dizziness. What action should the nurse take first?
- A. Check the client's blood glucose level.
- B. Check the client's vital signs and blood pressure.
- C. Decrease the infusion rate of TPN.
- D. Administer antiemetic medication as prescribed.
Correct answer: B
Rationale: When a client receiving total parenteral nutrition (TPN) reports symptoms like nausea and dizziness, the first action the nurse should take is to check the client's vital signs and blood pressure. This assessment helps determine the client's overall stability and can provide crucial information to guide further interventions. Checking the blood glucose level (Choice A) may be relevant but is not the priority in this situation. Decreasing the infusion rate of TPN (Choice C) may be necessary but should be based on assessment findings. Administering antiemetic medication (Choice D) should not be the initial action without first assessing the client's vital signs.
5. A client with cirrhosis develops ascites. What is the nurse’s priority intervention?
- A. Administer diuretics as prescribed.
- B. Restrict fluid intake to manage fluid overload.
- C. Position the client in Fowler’s position and assess for respiratory distress.
- D. Measure the client's abdominal girth daily.
Correct answer: B
Rationale: The correct answer is B: Restrict fluid intake to manage fluid overload. In a client with cirrhosis developing ascites, the priority intervention is to restrict fluid intake. This helps manage fluid overload, prevent further complications, such as respiratory distress or kidney impairment, and reduce the accumulation of ascitic fluid. Administering diuretics may be a part of the treatment plan, but the primary focus should be on fluid restriction. Positioning the client in Fowler’s position and measuring the abdominal girth are important interventions but not the priority when managing ascites in cirrhosis.
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