HESI RN
HESI Exit Exam RN Capstone
1. A client with multiple sclerosis is experiencing fatigue. What is the nurse's priority intervention?
- A. Encourage the client to increase physical activity.
- B. Encourage the client to take rest breaks during activities.
- C. Administer a stimulant medication to reduce fatigue.
- D. Advise the client to use energy conservation techniques.
Correct answer: D
Rationale: The correct answer is D: Advise the client to use energy conservation techniques. Energy conservation techniques are crucial in managing fatigue in multiple sclerosis. These techniques involve prioritizing activities, pacing oneself, and taking rest breaks to prevent overexertion, which can exacerbate fatigue. Encouraging the client to increase physical activity (choice A) may worsen fatigue if not done with proper energy conservation. Taking rest breaks during activities (choice B) is important but falls secondary to teaching energy conservation techniques. Administering a stimulant medication to reduce fatigue (choice C) should not be the priority as non-pharmacological interventions like energy conservation should be attempted first.
2. A client with dysphagia is having difficulty swallowing medications. What is the nurse's best intervention?
- A. Crush the medications and mix them with applesauce.
- B. Encourage the client to drink water with each dose.
- C. Consult with the healthcare provider about switching to liquid medications.
- D. Offer the client soft foods to reduce difficulty swallowing.
Correct answer: C
Rationale: The best intervention for a client with dysphagia experiencing difficulty swallowing medications is to consult with the healthcare provider about switching to liquid medications. Liquid medications are often easier to swallow and can reduce the risk of choking and aspiration in clients with dysphagia. Crushing medications can alter their effectiveness, encouraging the client to drink water may not be sufficient, and offering soft foods is not directly related to improving medication swallowing.
3. A client with schizophrenia is experiencing paranoia. What is the nurse's priority intervention?
- A. Reassure the client that their fears are unfounded.
- B. Place the client in a private room to reduce stimuli.
- C. Provide the client with a distraction to redirect their attention.
- D. Encourage the client to express their concerns and validate their feelings.
Correct answer: D
Rationale: Encouraging clients with paranoia to express their concerns and validating their feelings is crucial as it helps establish trust and reduce anxiety. This approach also aids in building a therapeutic relationship. Reassuring the client that their fears are unfounded (Choice A) may invalidate their feelings and worsen trust. Placing the client in a private room to reduce stimuli (Choice B) may be helpful in some situations but does not address the underlying issue of paranoia. Providing a distraction (Choice C) may temporarily shift the client's focus but does not address the root cause of the paranoia. Therefore, the priority intervention is to encourage the client to express their concerns and validate their feelings.
4. A client is receiving a blood transfusion and reports feeling chilled and short of breath. What is the nurse's priority action?
- A. Stop the transfusion and notify the healthcare provider.
- B. Administer an antihistamine as prescribed.
- C. Administer a dose of acetaminophen.
- D. Administer a PRN dose of diphenhydramine.
Correct answer: A
Rationale: The correct action for the nurse to take when a client receiving a blood transfusion reports feeling chilled and short of breath is to stop the transfusion immediately and notify the healthcare provider. These symptoms could indicate a transfusion reaction, which can be serious and even life-threatening. Stopping the transfusion is crucial to prevent further adverse reactions, and notifying the healthcare provider ensures timely intervention and appropriate management. Administering antihistamines, acetaminophen, or diphenhydramine is not the priority in this situation and may delay necessary actions to address the potential transfusion reaction.
5. A client with gastroesophageal reflux disease (GERD) is prescribed omeprazole. What is the primary purpose of this medication?
- A. Coat the lining of the stomach
- B. Neutralize stomach acid
- C. Promote gastric motility
- D. Reduce gastric acid secretion
Correct answer: D
Rationale: The correct answer is D: Reduce gastric acid secretion. Omeprazole is a proton pump inhibitor that works by reducing the production of gastric acid in the stomach. This helps in managing GERD by decreasing the acidity levels in the stomach. Choice A is incorrect because omeprazole does not coat the lining of the stomach. Choice B is incorrect as omeprazole does not neutralize stomach acid but rather reduces its production. Choice C is incorrect because omeprazole does not promote gastric motility; instead, it acts on acid secretion.
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