HESI RN
HESI 799 RN Exit Exam Capstone
1. A client with osteoarthritis is prescribed acetaminophen. What is the most important teaching the nurse should provide?
- A. Take the medication with food to improve absorption.
- B. Avoid taking other pain medications to prevent liver damage.
- C. Take acetaminophen on an empty stomach to prevent stomach upset.
- D. Monitor liver function tests regularly to detect any liver damage.
Correct answer: B
Rationale: The correct answer is B. Acetaminophen can cause liver damage if taken in excessive amounts or in combination with other medications containing acetaminophen. Clients should be advised to avoid other pain medications to prevent liver toxicity. Choice A is incorrect because acetaminophen is usually taken with or without food, not specifically on an empty stomach. Choice C is incorrect because taking acetaminophen with food can help prevent stomach upset. Choice D is incorrect because while monitoring liver function tests is important for long-term acetaminophen use, the most crucial teaching is to avoid other pain medications to prevent liver damage.
2. A client is admitted to the emergency department after a motor vehicle accident. The client has a Glasgow Coma Scale (GCS) score of 10. What does this score indicate?
- A. Mild impairment
- B. Moderate impairment
- C. Severe impairment
- D. Normal
Correct answer: B
Rationale: A Glasgow Coma Scale score of 10 falls into the range of moderate impairment, indicating the need for further assessment and monitoring. A GCS score of 10 suggests that the client is moderately impaired neurologically. Choices A, C, and D are incorrect because a GCS score of 10 does not indicate mild impairment, severe impairment, or normal neurological status, respectively.
3. A client with acute pancreatitis is experiencing severe abdominal pain. Which intervention should the nurse implement to help manage the client's pain?
- A. Encourage deep breathing exercises
- B. Place the client in a side-lying position with knees bent
- C. Administer oral analgesics as prescribed
- D. Encourage the client to take small sips of water
Correct answer: B
Rationale: The correct intervention to help manage the client's pain in acute pancreatitis is to place the client in a side-lying position with knees bent. This position can alleviate abdominal pain by reducing pressure on the pancreas and improving comfort. Encouraging deep breathing exercises (Choice A) is beneficial for other conditions but may not directly help alleviate abdominal pain in pancreatitis. Administering oral analgesics (Choice C) may be necessary but is not the initial priority for managing pain in acute pancreatitis. Encouraging the client to take small sips of water (Choice D) is important for hydration but is not directly related to pain management in this context.
4. The healthcare provider is assessing a client who has just received anesthesia. What is the most critical finding to report to the healthcare provider?
- A. Client reports dizziness
- B. Client has a drop in blood pressure
- C. Client experiences mild nausea
- D. Client reports dry mouth
Correct answer: B
Rationale: A significant drop in blood pressure following anesthesia could indicate a serious reaction, such as hypovolemia or anesthetic-induced hypotension. This requires immediate medical attention, while other symptoms like dizziness, mild nausea, and dry mouth are more common and less critical. Dizziness could be expected due to the effects of anesthesia, mild nausea is a common side effect, and dry mouth is a known effect of anesthesia as well.
5. A client with diabetes mellitus is admitted with an infected foot ulcer. What intervention is most important for the nurse to implement?
- A. Obtain a wound culture for testing.
- B. Administer prescribed IV antibiotics.
- C. Elevate the affected foot to reduce swelling.
- D. Consult the wound care nurse for assessment.
Correct answer: B
Rationale: Administering prescribed IV antibiotics is the most crucial intervention in managing an infected foot ulcer in a client with diabetes mellitus. Antibiotics help combat the infection and prevent its spread systemically, which is vital in diabetic clients to prevent serious complications like sepsis. While obtaining a wound culture (Choice A) may provide valuable information for targeted antibiotic therapy, administering antibiotics promptly takes precedence to prevent the infection from worsening. Elevating the affected foot (Choice C) can help reduce swelling but is not as urgent as administering antibiotics. Consulting the wound care nurse (Choice D) may be beneficial for long-term wound management but does not address the immediate need to control the infection.
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