HESI RN
HESI RN Exit Exam Capstone
1. A scrub nurse preparing for the first surgery of the day asks if a 3-minute surgical hand scrub is adequate. What should the circulating nurse advise?
- A. Proceed with surgery preparation
- B. Extend scrub time to 5 minutes
- C. Use an alcohol-based hand sanitizer
- D. Scrub time depends on the type of surgery
Correct answer: B
Rationale: The circulating nurse should advise the scrub nurse to extend the hand scrub to 5 minutes for thorough preparation, especially for the first surgery of the day. Choice A is incorrect as it does not address the need for a longer scrub time. Choice C is incorrect as alcohol-based hand sanitizer is not a substitute for a thorough surgical hand scrub. Choice D is incorrect as while scrub time may vary based on the surgery, for the first surgery of the day, a longer scrub time is recommended as a standard practice.
2. When teaching a group of mothers of young children about emergency care for poisoning, which of the following statements should be included?
- A. Induce vomiting immediately after the poison ingestion
- B. Call the local Poison Control Center after inducing vomiting
- C. Call the Poison Control Center prior to any interventions
- D. Take the child to the emergency department before calling the Poison Control Center
Correct answer: C
Rationale: The correct statement to include when teaching about emergency care for poisoning is to call the Poison Control Center prior to any interventions. This is important because the Poison Control Center can provide guidance on the appropriate steps to take based on the type of poisoning, the amount ingested, and the age of the child. Inducing vomiting without professional advice can sometimes do more harm than good. Choice A is incorrect because inducing vomiting immediately is not recommended without consulting with professionals. Choice B is incorrect as it suggests calling the Poison Control Center after inducing vomiting, which is not the recommended sequence. Choice D is incorrect because it is advisable to contact the Poison Control Center first before taking the child to the emergency department.
3. A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated serum amylase. Which additional information is the client most likely to report to the nurse?
- A. Pain radiates to the back
- B. Nausea and vomiting without relief
- C. Abdominal pain decreases when lying supine
- D. Abdominal pain is worse after eating
Correct answer: D
Rationale: The correct answer is D. In acute pancreatitis, abdominal pain typically worsens after eating due to the stimulation of the pancreas to release enzymes that irritate the inflamed tissues. Pain relief when lying supine is uncommon and usually exacerbates discomfort. While nausea and vomiting are common symptoms, they are not as indicative of changes in pain intensity. Pain radiating to the back is characteristic but does not specifically relate to exacerbation post-eating.
4. A client is experiencing chest pain and is prescribed nitroglycerin. What should the nurse assess before administering the medication?
- A. Monitor the client’s oxygen saturation level.
- B. Check the client’s heart rate and blood pressure.
- C. Evaluate the client’s level of consciousness.
- D. Assess the client's chest pain severity using a pain scale.
Correct answer: B
Rationale: Before administering nitroglycerin, it is crucial to check the client’s heart rate and blood pressure. Nitroglycerin can lower blood pressure and heart rate, so assessing these parameters is essential to prevent exacerbating hypotension or bradycardia. While monitoring the client’s oxygen saturation level is important in some situations, it is not the primary assessment needed before administering nitroglycerin. Evaluating the client’s level of consciousness is relevant for other conditions but not specifically necessary before giving nitroglycerin. Assessing chest pain severity using a pain scale is valuable for pain management but is not the priority assessment before administering nitroglycerin.
5. The nurse is assessing a client with a history of schizophrenia who reports feeling sedated after starting a new antipsychotic medication. Which intervention is most appropriate?
- A. Reassure the client that sedation will subside with continued use
- B. Instruct the client to take the medication at bedtime
- C. Teach the client to take the medication with food
- D. Consult the healthcare provider to reduce the dosage
Correct answer: B
Rationale: Instructing the client to take the medication at bedtime is the most appropriate intervention. Taking antipsychotic medications at bedtime can help reduce the impact of sedation on the client's daily activities. This approach allows the client to sleep through the sedative effects. Choice A is incorrect because just reassuring the client may not address the immediate issue of sedation. Choice C is incorrect as taking the medication with food does not directly address the sedation concern. Choice D is not the first-line intervention; adjusting the dosage should be done by the healthcare provider after assessing the client's response to the medication.
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