HESI RN
HESI Exit Exam RN Capstone
1. The nurse is administering a new medication to a client. What is the priority action before administering the drug?
- A. Verify the client's allergies
- B. Check the client's blood pressure
- C. Assess the client's pain level
- D. Provide client education on the medication
Correct answer: A
Rationale: Verifying the client's allergies is the priority action before administering any medication. It is crucial to identify any known allergies to prevent potential allergic reactions, which can be severe and life-threatening. Checking the client's blood pressure, assessing pain levels, and providing education on the medication are important aspects of client care but verifying allergies is essential for ensuring the safety of the client.
2. A client with rheumatoid arthritis is prescribed disease-modifying antirheumatic drugs (DMARDs). What should the nurse monitor for?
- A. Monitor for signs of liver toxicity.
- B. Assess for gastrointestinal side effects, such as nausea or diarrhea.
- C. Monitor for signs of infection, such as fever or sore throat.
- D. Administer DMARDs with meals to prevent gastrointestinal upset.
Correct answer: C
Rationale: Correct Answer: Monitoring for signs of infection, such as fever or sore throat, is crucial when a client with rheumatoid arthritis is prescribed disease-modifying antirheumatic drugs (DMARDs). DMARDs can suppress the immune system, making individuals more susceptible to infections. Early detection of infections allows for prompt treatment and helps prevent complications. Choices A, B, and D are incorrect because while liver toxicity and gastrointestinal side effects are possible side effects of DMARDs, monitoring for signs of infection takes priority due to the increased risk of infections associated with these medications.
3. The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to
- A. Exercise doing weight-bearing activities
- B. Exercise to reduce weight
- C. Avoid exercise activities that increase the risk of fracture
- D. Exercise to strengthen muscles and thereby protect bones
Correct answer: A
Rationale: Weight-bearing exercises are crucial in managing osteoporosis as they help strengthen bones. Choice A is the correct answer because weight-bearing activities, such as walking, dancing, or weight training, help stimulate bone formation and strengthen bones, which is essential in managing osteoporosis. Choice B is incorrect as the primary focus should be on the type of exercise rather than weight reduction. Choice C is incorrect because avoiding exercise altogether can lead to further bone density loss, and it is important to engage in safe weight-bearing activities. Choice D is incorrect as the primary goal of exercise in osteoporosis is to improve bone density through weight-bearing activities.
4. 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.
5. A client is admitted with a suspected pulmonary embolism (PE). What is the nurse's priority intervention?
- A. Administer anticoagulant therapy as prescribed.
- B. Elevate the head of the bed to 45 degrees.
- C. Check the client's oxygen saturation.
- D. Prepare the client for a CT scan.
Correct answer: D
Rationale: The correct answer is to prepare the client for a CT scan. A CT scan is essential in confirming the presence of a pulmonary embolism (PE) and guiding further treatment. Administering anticoagulant therapy (Choice A) is important in the management of PE, but it is not the priority intervention in this case. Elevating the head of the bed (Choice B) is beneficial for optimizing oxygenation but is not the priority intervention when a PE is suspected. Checking the client's oxygen saturation (Choice C) is important, but obtaining a definitive diagnosis through a CT scan takes precedence in this situation.
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