HESI RN
HESI RN Exit Exam 2024 Quizlet Capstone
1. An older adult client with heart failure (HF) and hypertension (HTN) is receiving atenolol, furosemide, and enalapril. Which assessments are essential to evaluate the effectiveness of the medications?
- A. Bowel sounds and daily weight.
- B. Daily weight and blood pressure.
- C. Heart sounds and range of motion.
- D. Monitor for evidence of hypokalemia.
Correct answer: B
Rationale: Monitoring daily weight and blood pressure is crucial to assess the effectiveness of diuretics (furosemide) and antihypertensives (atenolol, enalapril) in managing heart failure and hypertension. Changes in weight indicate fluid status, while blood pressure readings reflect the control of hypertension. Assessing bowel sounds and range of motion are important but not directly related to evaluating the effectiveness of these specific medications in this scenario. Monitoring for hypokalemia is important due to furosemide's potential side effect, but it is not the primary assessment to evaluate medication effectiveness.
2. After surgery, a client has been taken off the ventilator and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?
- A. Allow the client to melt ice chips in the mouth
- B. Provide mints to freshen the breath
- C. Perform frequent oral care with a tooth sponge
- D. Swab the mouth with glycerin swabs
Correct answer: C
Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure in this situation. It helps maintain oral hygiene, prevent dryness, and provide comfort for a client with an NG tube. Allowing the client to melt ice chips may not be suitable immediately post-surgery due to potential risks. Providing mints or swabbing the mouth with glycerin swabs may not address the need for proper oral care and hygiene, which is essential for a client with an NG tube.
3. The healthcare provider is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the healthcare provider withhold the drug?
- A. Respiratory rate of 22 breaths/min
- B. A large amount of lochia rubra
- C. Blood pressure 149/90
- D. Positive Homan’s sign
Correct answer: C
Rationale: A blood pressure of 149/90 is an indication to withhold Methergine due to its potential to further increase blood pressure. Methergine is a medication that can cause vasoconstriction, leading to elevated blood pressure. In this case, administering Methergine could exacerbate the elevated blood pressure, posing a risk to the patient. Therefore, it is crucial to withhold the medication in the presence of hypertension to prevent adverse effects. The other options are not directly related to the administration of Methergine. A respiratory rate of 22 breaths/min is within the normal range. A large amount of lochia rubra may indicate normal postpartum bleeding. A positive Homan’s sign is associated with deep vein thrombosis, which is not a contraindication for administering Methergine.
4. What is the recommended analgesia for preparing a school-age child for a lumbar puncture (LP)?
- A. Ondansetron (Zofran) 4 mg / 5 ml PO TID.
- B. Codeine 10 mg PO 30 minutes before the procedure.
- C. A transdermal fentanyl (Duragesic) patch immediately before the procedure.
- D. EMLA (eutectic mixtures of local anesthetics) 2.5 hours before the procedure.
Correct answer: D
Rationale: For a lumbar puncture in a school-age child, EMLA cream should be applied 2.5 hours before the procedure. EMLA is commonly used to numb the skin, reducing pain and discomfort for the child during the procedure. Choices A, B, and C are incorrect because ondansetron is an antiemetic, codeine is an opioid analgesic that may not be suitable for children, and transdermal fentanyl is a strong opioid that is not typically used for local anesthesia in children undergoing lumbar puncture.
5. A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the deceased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time?
- A. Not sleeping for several days.
- B. Wishing to be with the deceased significant other.
- C. Lack of interest in usual activities.
- D. Eating very little.
Correct answer: A
Rationale: The most important client statement for the RN to explore in this scenario is the client not sleeping for several days. The lack of sleep is a critical indicator of possible severe depression or suicidal ideation that requires immediate attention. While expressing a wish to be with the deceased significant other, having a lack of interest in usual activities, and eating very little are concerning, the immediate focus should be on the client's severe sleep disturbance as it can pose an immediate risk to their well-being and safety.