HESI RN
HESI RN Exit Exam Capstone
1. 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.
2. The client has had a femoral-popliteal bypass surgery 6 hours ago. Which assessment provides the most accurate information about the client's postoperative status?
- A. Radial pulse.
- B. Femoral pulse.
- C. Apical pulse.
- D. Dorsalis pedis pulse.
Correct answer: D
Rationale: Assessing the dorsalis pedis pulse is crucial after a femoral-popliteal bypass surgery to determine adequate circulation distal to the surgical site. A strong dorsalis pedis pulse indicates sufficient blood flow to the foot, which is essential for monitoring postoperative status. The radial pulse (A) is not the most relevant assessment as it does not provide direct information on circulation in the lower extremities. The femoral pulse (B) may not accurately reflect circulation distal to the surgical site. The apical pulse (C) is used primarily to assess the heartbeat and cardiac function, not circulation in the lower extremities.
3. After delegating to an unlicensed assistive personnel (UAP) the task of completing a bladder scan examination for a client, the nurse evaluates the UAP’s performance. Which action by the UAP indicates the nurse must provide additional instructions when delegating this task?
- A. Selecting the female icon for all female clients and the male icon for all male clients
- B. Explaining to the client, 'This test measures the amount of urine in your bladder.'
- C. Applying ultrasound gel to the scanning head and cleaning it after use
- D. Taking at least two readings using the aiming icon to position the scanning head
Correct answer: A
Rationale: The correct answer is A because the UAP should select the female icon for women who have not had a hysterectomy to allow the scanner to subtract the volume of the uterus from readings. If a woman has had a hysterectomy, the UAP should choose the male icon. Choice B is incorrect as it is essential for the UAP to explain the procedure to the client to ensure understanding. Choice C is incorrect because applying ultrasound gel to the scanning head and cleaning it after use are appropriate actions. Choice D is incorrect as it is necessary for the UAP to take at least two readings using the aiming icon to position the scanning head accurately for an effective bladder scan examination.
4. A client with nephrotic syndrome is being assessed by a nurse. For which clinical manifestations should the nurse assess? (Select all that apply.)
- A. Proteinuria
- B. Hypoalbuminemia
- C. Lipiduria
- D. All of the above
Correct answer: D
Rationale: Nephrotic syndrome is characterized by glomerular damage, leading to proteinuria (excessive protein in the urine), hypoalbuminemia (low levels of albumin in the blood), and lipiduria (lipids in the urine). These manifestations are key indicators of nephrotic syndrome. Edema, often severe, is also common due to decreased plasma oncotic pressure from hypoalbuminemia. The correct answer is 'All of the above' because all three manifestations are associated with nephrotic syndrome. Dehydration is not a typical finding in nephrotic syndrome as it is more commonly associated with fluid retention and edema. Dysuria is a symptom of cystitis, not nephrotic syndrome. CVA tenderness is more indicative of inflammatory changes in the kidney rather than nephrotic syndrome.
5. A client who is 32-weeks pregnant is diagnosed with partial placenta previa. Which instruction should the nurse include in this client’s teaching plan?
- A. Wear a tight abdominal binder at all times
- B. Take a daily laxative to prevent constipation
- C. Refrain from sexual intercourse until your next appointment
- D. Restrict fluids to less than 1000 ml per day
Correct answer: C
Rationale: Refraining from sexual intercourse helps prevent complications with partial placenta previa.