HESI RN
RN HESI Exit Exam Capstone
1. A mother reports that she has been applying triple antibiotic ointment for her son's athlete's foot for two days with no improvement. What should the nurse instruct?
- A. Continue using the ointment and keep the area clean.
- B. Stop using the ointment and encourage the feet to be dried completely.
- C. Apply a different antifungal medication instead.
- D. Reapply the ointment twice a day for a longer period.
Correct answer: B
Rationale: Antibiotic ointment is ineffective against athlete's foot, which is a fungal infection. The nurse should instruct the mother to stop using the ointment and ensure the feet are dried properly, as moisture exacerbates fungal infections. Applying a different antifungal medication is a valid option, but addressing the moisture issue by drying the feet completely is the immediate priority. Continuing to use the antibiotic ointment or reapplying it for a longer period will not treat the fungal infection effectively.
2. An adult client with a broken femur reports muscle spasms. What action should the nurse implement while awaiting surgery?
- A. Check the client's most recent electrolyte levels.
- B. Administer a PRN dose of muscle relaxant.
- C. Reduce the weight on the traction device.
- D. Encourage oral fluid intake to relieve muscle tension.
Correct answer: D
Rationale: The correct action for the nurse to implement while awaiting surgery for a client with muscle spasms due to a broken femur is to encourage oral fluid intake to relieve muscle tension. Dehydration can exacerbate muscle spasms, so increasing fluid intake can help alleviate them. Checking electrolyte levels may not directly address muscle spasms in this situation. Administering a muscle relaxant should be based on a healthcare provider's prescription, and traction weight adjustments should only be made by the provider overseeing the client's care.
3. The nurse is preparing to administer a blood transfusion to a client. Which action is most important for the nurse to take before starting the transfusion?
- A. Administer pre-transfusion medication
- B. Ensure the client has an adequate fluid intake
- C. Monitor the client's vital signs
- D. Verify the blood type with another nurse
Correct answer: D
Rationale: Verifying the blood type with another nurse is critical before starting a blood transfusion to prevent a potentially life-threatening transfusion reaction. This step ensures that the client receives the correct blood product. Administering pre-transfusion medication, ensuring adequate fluid intake, and monitoring vital signs are important steps during the transfusion process, but verifying the blood type is the most crucial step to ensure patient safety.
4. An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take?
- A. Perform a 12-lead electrocardiogram
- B. Document in the client's record
- C. Notify the healthcare provider immediately
- D. Assess for signs of heart failure
Correct answer: B
Rationale: An S3 heart sound is often a normal finding in pregnant women due to increased blood volume and cardiac output. The nurse should document the finding as part of the routine assessment unless accompanied by other abnormal symptoms. Performing a 12-lead electrocardiogram (Choice A) is unnecessary for a normal S3 heart sound in pregnancy. Notifying the healthcare provider immediately (Choice C) is premature and may lead to unnecessary interventions. Assessing for signs of heart failure (Choice D) is not indicated as an isolated S3 heart sound is typically benign in pregnancy.
5. A client is admitted to the hospital with a diagnosis of pneumonia. The client is prescribed intravenous antibiotics and oxygen therapy. Which assessment finding indicates that the client's condition is improving?
- A. Increased white blood cell count
- B. Crackles heard on lung auscultation
- C. Productive cough with green sputum
- D. Decreased respiratory rate from 24 to 18 breaths per minute
Correct answer: D
Rationale: A decrease in respiratory rate indicates that the client's breathing is becoming more stable, which suggests an improvement in their condition. Respiratory rate is a critical indicator of respiratory status and oxygenation. Increased white blood cell count (choice A) suggests ongoing infection, crackles on lung auscultation (choice B) indicate fluid in the lungs, and productive cough with green sputum (choice C) may indicate persistent infection or airway inflammation, which do not necessarily reflect improvement in pneumonia.
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