HESI RN
HESI RN Exit Exam 2024 Quizlet Capstone
1. The healthcare provider prescribes a sedative for a client with severe hypothyroidism. What is the best action for the nurse to take?
- A. Affirm the nurse's plan to review the prescription with the provider.
- B. Administer the sedative as prescribed.
- C. Advise the nurse to administer the medication as prescribed.
- D. Offer to administer the medication since the nurse is concerned.
Correct answer: A
Rationale: The correct answer is to affirm the nurse's plan to review the prescription with the provider. Sedatives can worsen symptoms of hypothyroidism, so it is crucial to ensure the safety of the prescribed medication. Administering the sedative without further consultation could lead to adverse effects. Simply advising the nurse to administer the medication without addressing the need for review is not the best course of action. Offering to administer the medication without proper assessment or consulting the provider is not appropriate and could potentially harm the client.
2. Which intervention should be prioritized by the nurse when assessing tissue perfusion post-above knee amputation (AKA)?
- A. Evaluate the closest proximal pulse.
- B. Observe color and amount of wound drainage.
- C. Observe for swelling around the stump.
- D. Assess the skin elasticity of the stump.
Correct answer: A
Rationale: The correct answer is to evaluate the closest proximal pulse when assessing tissue perfusion post-above knee amputation (AKA). Checking the closest proximal pulse provides the best indication of tissue perfusion in the extremities after an AKA procedure. Observing the color and amount of wound drainage (Choice B) is important for wound care but does not directly assess tissue perfusion. Observing for swelling around the stump (Choice C) may indicate inflammation or fluid accumulation but is not the most direct way to assess tissue perfusion. Assessing the skin elasticity of the stump (Choice D) is more related to skin integrity and wound healing rather than tissue perfusion.
3. 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.
4. Which self-care measure is most important for the nurse to include in the plan of care of a client recently diagnosed with type 2 diabetes mellitus?
- A. Maintaining a low-sugar diet
- B. Foot care
- C. Blood glucose monitoring
- D. Daily exercise
Correct answer: C
Rationale: Blood glucose monitoring is crucial for managing diabetes effectively. By monitoring blood sugar levels, individuals can understand how their lifestyle choices, medications, and diet affect their glucose levels. This information helps in making necessary adjustments to control blood sugar levels and prevent complications. While maintaining a low-sugar diet, foot care, and daily exercise are all important aspects of managing diabetes, blood glucose monitoring takes precedence as it provides real-time data for informed decision-making.
5. A client with a recent myocardial infarction is prescribed a beta-blocker. What side effect should the nurse monitor for?
- A. Monitor the client for bradycardia.
- B. Check the client’s blood pressure for signs of hypotension.
- C. Monitor the client for signs of hyperglycemia.
- D. Monitor for signs of fluid retention.
Correct answer: B
Rationale: The correct answer is B: 'Check the client’s blood pressure for signs of hypotension.' Beta-blockers can lead to decreased heart rate, but bradycardia is not the primary side effect to monitor. Monitoring for bradycardia is more relevant when administering medications like digoxin. Hyperglycemia is associated with medications like corticosteroids, not beta-blockers. Fluid retention is a side effect seen with medications like corticosteroids or calcium channel blockers, not beta-blockers. Therefore, in a client taking a beta-blocker after a myocardial infarction, monitoring for hypotension is crucial due to the medication's mechanism of action.
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