HESI RN
HESI Exit Exam RN Capstone
1. An adolescent with intellectual disability is admitted for refusing to complete oral hygiene. A behavior modification program is recommended. Which reinforcement is best?
- A. Unit tasks for each omitted teeth brushing.
- B. Candy for each successfully completed hygiene task.
- C. Privilege restriction for refusing hygiene tasks.
- D. Preferred activities or tokens for compliance.
Correct answer: D
Rationale: The best reinforcement strategy in this scenario is providing preferred activities or tokens for compliance. Positive reinforcement is effective in behavior modification programs for individuals with intellectual disabilities. Offering preferred activities or tokens serves as a reward for completing the desired behavior, in this case, oral hygiene tasks. Choices A, B, and C do not focus on reinforcing the desired behavior with positive incentives. Choice A does not provide a positive reinforcement for compliance but rather focuses on the omission of a task. Choice B uses candy, which may not be ideal for oral hygiene. Choice C involves punishment rather than positive reinforcement.
2. The nurse is caring for a client with acute pancreatitis who is reporting severe abdominal pain. Which nursing intervention should the nurse implement first?
- A. Assess the client's bowel sounds
- B. Administer prescribed pain medication
- C. Encourage the client to sit upright
- D. Provide clear fluids to the client
Correct answer: B
Rationale: In a client with acute pancreatitis experiencing severe abdominal pain, the priority nursing intervention is to provide pain relief. Administering prescribed pain medication is essential to improve comfort and reduce pain, which can help stabilize the client's condition. Assessing bowel sounds (Choice A) may be necessary but is not the immediate priority over pain management. Encouraging the client to sit upright (Choice C) and providing clear fluids (Choice D) are not the primary interventions for addressing severe abdominal pain in acute pancreatitis.
3. The nurse is planning to administer two medications at 0900. Which property of the drugs indicates a need to monitor the client for toxicity?
- A. Short half-life
- B. High therapeutic index
- C. Highly protein-bound
- D. Low bioavailability
Correct answer: C
Rationale: The correct answer is C, 'Highly protein-bound.' Drugs that are highly protein-bound can displace from protein-binding sites, leading to increased free drug levels in the blood, which can result in toxicity. Monitoring the client for toxicity is crucial when administering highly protein-bound drugs. Choices A, B, and D are incorrect. A short half-life does not necessarily indicate a need for monitoring toxicity; a high therapeutic index indicates a wide safety margin between the effective dose and the toxic dose, reducing the risk of toxicity; low bioavailability refers to the fraction of the drug that reaches the systemic circulation unchanged and does not directly relate to the risk of toxicity.
4. A client with adrenal crisis has a temperature of 102°F, heart rate of 138 bpm, and blood pressure of 80/60 mmHg. Which action should the nurse implement first?
- A. Obtain an analgesic prescription.
- B. Infuse intravenous fluid bolus.
- C. Administer PRN oral antipyretic.
- D. Cover the client with a cooling blanket.
Correct answer: B
Rationale: In a client with adrenal crisis presenting with a high temperature, tachycardia, and hypotension, the priority action for the nurse to implement first is to infuse an intravenous fluid bolus. This intervention aims to address the hypotension by increasing the circulating volume and improving perfusion. Obtaining an analgesic prescription (Choice A) is not the priority in this situation. Administering an oral antipyretic (Choice C) may help reduce the fever but does not address the primary issue of hypotension. Covering the client with a cooling blanket (Choice D) may help with temperature control but does not address the hemodynamic instability caused by the adrenal crisis.
5. A client has suspected compartment syndrome of the right lower leg. What is the nurse’s priority intervention?
- A. Elevate the right leg to reduce swelling.
- B. Loosen any restrictive dressings on the leg.
- C. Prepare the client for emergency surgery.
- D. Administer pain medication as prescribed.
Correct answer: B
Rationale: In a suspected case of compartment syndrome, the nurse's priority intervention is to loosen any restrictive dressings on the leg. This action helps to relieve pressure within the affected compartment, improve circulation, and prevent permanent damage. Elevating the leg may further increase pressure, preparing for emergency surgery is premature without proper assessment and diagnosis, and administering pain medication should come after addressing the primary issue of relieving pressure.
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