HESI RN
HESI RN Exit Exam Capstone
1. After administering a proton pump inhibitor, which action should the nurse take to evaluate the effectiveness of the medication?
- A. Monitor gastrointestinal pain
- B. Ask the client about pain levels
- C. Check the client's vital signs
- D. Assess for signs of bleeding
Correct answer: B
Rationale: The correct answer is to ask the client about pain levels. Proton pump inhibitors (PPIs) work by reducing stomach acid to alleviate gastrointestinal pain. By inquiring about the client's pain experience, the nurse can directly assess the effectiveness of the medication. Monitoring bowel movements (Choice A) is not directly related to evaluating the effectiveness of a PPI. Checking vital signs (Choice C) may not reflect the medication's effectiveness in reducing stomach acid. Assessing for signs of bleeding (Choice D) is important but not the most direct way to evaluate the effectiveness of a PPI.
2. The healthcare provider is caring for a client with severe anemia. Which assessment finding requires immediate intervention?
- A. Pale skin
- B. Increased heart rate
- C. Shortness of breath
- D. Fatigue
Correct answer: C
Rationale: Shortness of breath is a critical sign in severe anemia as it indicates inadequate oxygenation, which can be life-threatening. Immediate intervention is necessary to address this condition. Pale skin (choice A) is a common finding in anemia but not as urgent as shortness of breath. Increased heart rate (choice B) is a compensatory mechanism in anemia to maintain oxygen delivery and is important but not as urgent as addressing inadequate oxygenation. Fatigue (choice D) is a common symptom in anemia but does not indicate an immediate life-threatening situation like shortness of breath does.
3. When assessing a client with a diagnosis of bipolar disorder who reports taking a handful of medications, what information is most important to obtain?
- A. What drugs the client used in the suicide attempt.
- B. When the client last took medications for bipolar disorder.
- C. Whether the client has attempted suicide before.
- D. Which family member has the suicide note.
Correct answer: A
Rationale: The correct answer is to obtain information on what drugs the client used in the suicide attempt. This information is crucial for assessing the severity of the overdose, potential drug interactions, and determining the appropriate treatment plan. Choice B is not as urgent as identifying the drugs taken during the suicide attempt. Choice C, while important, is not as immediately critical as knowing the specific medications involved. Choice D is unrelated to the immediate medical needs of the client.
4. A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to the child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. Which action should the nurse take?
- A. Involve the older brother in supporting the child
- B. Ask the older brother how he felt during the incident
- C. Ask the parents for more information about the brother's behavior
- D. Reassure the brother that everything is fine now
Correct answer: B
Rationale: The older brother's withdrawal likely indicates emotional trauma or stress from the near-drowning event. Asking how he felt provides an opportunity for emotional support and allows the child to express feelings that may need addressing. Involving him in supporting the child may be overwhelming and not address his emotional needs directly. Asking the parents for more information may not allow the older brother to express his own feelings. Simply reassuring him that everything is fine now may dismiss his emotional experience without providing a chance for him to process his feelings.
5. What is the primary purpose of the logrolling technique for turning?
- A. To decrease the risk of back injury by working together.
- B. To maintain straight spinal alignment.
- C. To increase client safety by using two or three people.
- D. To reduce the likelihood of skin damage by turning instead of pulling.
Correct answer: B
Rationale: The correct answer is B: To maintain straight spinal alignment. Logrolling is a technique used to carefully turn a client while keeping the spine in a straight line, especially important for those with spinal injuries or after back surgery. Choice A is incorrect because the primary purpose is not specifically to decrease the risk of back injury but to ensure safe turning. Choice C is incorrect as the main aim is not to increase client safety by using multiple people but to protect the spine. Choice D is incorrect because the primary purpose of logrolling is not to prevent skin damage but to safeguard the spine during turning.
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